Full text of "Journal of the Iowa Medical Society"

See other formats

Digitized by the Internet Archive
in 2016 with funding from

The National Endowment for the Humanities and the Arcadia Fund

https://archive.org/details/journalofiowamed52unse

• Fractures About the Elbow in Children,

page I

• Open Fractures, page 7

• Nylon Lace-Mesh in Fixation of Skin

Grafts, page 14

• Visual Responses to Cortical

Stimulation in the Blind, page 1 7

a look
at the
literature

U.c. MEDICAL CENTER LISRARY
JAN 8 1962

San Francisco, 22

an excellent drug

Based both

on laboratory studies and clinical
impressions, it [Cordran] appears to
be an excellent drug for the relief of
cutaneous inflammation, possibly
more effective than any steroid we
have hitherto used. * -

— Rostenberg, A., Jr.: Clinical Evaluation of J J
Flurandrenolone, a New Steroid, in Der- ***

matological Practice, J. New Drugs, V. 1 18,

1961.

Description: Cordran cream and ointment
contain 0.5 mg. Cordran per Gm. Cordran™-N
cream and ointment contain 0.5 mg. Cordran
and 5 mg. neomycin sulfate per Gm.

Cordran™-N (flurandrenolone with neomycin sulfate, Lilly)

Product brochure available; write Eli Lilly and Company, Indianapolis 6, Indiana.
This is a reminder advertisement. For adequate information for use, please consult
manufacturer’s literature. 240209

JANUARY, 1962

when urinary fc
tract

infections
present
a therapeutic

challenge...

Often recurrent ... often resistant to treatment, urinary tract infections are among the most
fiequent and troublesome types of infections seen in clinical practice.1-2 In such infections,
successful therapy is usually dependent on identification and susceptibility testing of invad-
ing organisms, administration of appropriate antibacterial agents, and correction of obstruc-
tion or other underlying pathology.

Of these agents, one author reports : “Chloramphenicol still has the widest and most effective
activity range against infections of the urinary tract. It is particularly useful against the
co 1 01 m gioup, certain Proteus species, the micrococci and the enterococci.”1 CHLOROMYCETIN
is of particular value in the management of urinary tract infections caused by Escherichia
coli and Aerobacter aerogenes .3 In addition to these clinical findings, the wide antibacterial
range of CHLOROMYCETIN continues to be confirmed by recent in vitro studies.4'6

hrhotRCplYnfEl'fiN« QPheniCi01 ’ Pa.rke'Davis) is available in various forms, including Kapseals® of 250 mg
in bottles of 16 and 100. See package insert for details of administration and dosage. S ’’

and ®ven fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia,
^yt^P wuart knOWn t0 0CCUr after the adl™nistration of chloramphenicol. Blood dyscrasias have
occurred after both short-term and prolonged therapy with this drug. Bearing in mind the possibility that
uch leactmns may occur, chloramphenicol should be used only for serious infections caused by organisms
which are susceptible to its antibacterial effects. Chloramphenicol should not be used when other less poten

Sf 1* effeCtiVC' °r in the treatment »f Motions, such as coUs'Lfluenza or

, m^ectlonj of the throat, or as a prophylactic agent. Precautions: It is essential that adequate blood
siu les be made during treatment with the drug. While blood studies may detect early peripheral blood
changes, such as leukopenia or granulocytopenia, before they become irreversible, such studies cannot be
led upon to detect bone marrow depression prior to development of aplastic anemia

K a ’ \MiL \25 :836> 196°- (2) Martin- W J- • Nichols. D. R.. & Cook. E. N. .- Proc. Staff Meet Mayo CUr,
.14. 8, , 1959. (3; unman, A.: Delaware M. J. 32:97, 1960. (4) Petersdorf, R. G. ; Hook, E. W. • F V Ch '

>?Ul 'ih $ G™ssberg, S. E. : Bull. Johns Hopkins Hosp. 108:48, 1961. (5) Jolliff, C. R.’

694 196ao j P *V ^eidrifk- R J- & Cain- J- A.: Antibiotics & Chemother. 10:

0J4, i960. (6) Lind, H. E. : Am. J. Proctol. 11 :392, 1960

68961

PARKE-DAVIS

PARKE, DAVIS £ COM* . .

Vol. LI I

JANUARY, 1962

No. I

CONTENTS

SCIENTIFIC ARTICLES

Fractures About the Elbow in Children
Patrick J. Kelly, M.D., Rochester, Minnesota . 1

Open Fractures

Fred Reynolds, M.D., St. Louis, Missouri ... 7

Use of Nylon Lace-Mesh in Fixation of Split-
Thickness Skin Grafts

William Stanford, M.D., John E. Hutchinson,
M.D., and Sidney E. Ziffren, M.D., Iowa City 14

Visual Responses to Cortical Stimulation in the
Blind

John Button, M.D., Des Moines, and Tracy Put-

nam, M.D., Los Angeles 17

State University of Iowa College of Medicine
Clinical Pathologic Conference 22

EDITORIALS

Happy New Year 33

A Time and a Place 33

Induction of Labor 33

Prophylaxis for Rheumatic Fever 34

Isoniazid v. the Complications of Tuberculosis . . 35

Mores of Teenagers 36

SPECIAL DEPARTMENTS

Coming Meetings 32

President’s Page 37

The Journal Book Shelf 38

Iowa Chapter of the American Academy of General
Practice 40

The Doctor’s Business 46

Iowa Association of Medical Assistants .... 48

In the Public Interest Facing Page 48i

State Department of Health 49

Woman’s Auxiliary News 51

The Month in Washington xxxii

Personals xxxix

Deaths jjj|

MISCELLANEOUS

Treatment for Glaucoma 13

Sioux Valley Medical Association 16

Report from Europe 42

Tomorrow’s Challenge to the British Hospitals . 43

Patients Want Free Choice of Physician ... 47

Creative Child Product of Loosely-Organized Fam-
ily xxxvi

Alcohol Is the Primary Cause of Alcoholism . . liii

Instructional Movie on Nursery Sepsis .... liii

IOWA MEDICAL SOCIETY

EDITORS

Dennis H. Kelly, Sr., M.D., Scientific Editor Des Moines

Edward W. Hamilton, Ph.D., Managing Editor

Des Moines

SCIENTIFIC EDITORIAL PANEL

Walter M. Kirkendall, M.D Iowa City

Floyd M. Burgeson, M.D Des Moines

Daniel A. Glomset, M.D .Des Moines

Robert N. Larimer, M.D. Sioux City

Daniel F. Crowley, M.D Des Moines

PUBLICATION COMMITTEE

Samuel P. Leinbach, M.D Belmond

Otis D. Wolfe, M.D Marshalltown

Cecil W. Seibert, M.D Waterloo

Richard F. Birge, M.D., Secretary Des Moines

Dennis H. Kelly, Sr., M.D., Editor Ex Officio Des Moines

Address all communications to the Editor of the Jour-
nal, 529-36th Street, Des Moines 12

Postmaster, send form 3579 to the above address.

p<?stag,e paic* Fulton Missouri, and (for additional mailings) at Des Moines, Iowa. Publishe
ti?on Price- $3 00 PerY Year201'5 Bluff Street’ Fulton- Missouri. Editorial Office: 529-36th Street, Des Moines l:

monthly by the
Iowa. Subscrip-

Fractures About the Elbow
In Children

PATRICK J. KELLY, M.D.

Rochester, Minnesota

There has been enough clinical research on the
subject of fractures of the elbow region in chil-
dren to allow the presentation of the following
material.1-4 I approach this subject with humility,
bearing in mind that others have trod this path
before. Basically, I agree with the approach that
authorities have made to these injuries, but I shall
present, in a rather dogmatic fashion, the methods
that have worked for me. In doing so, I don’t mean
to imply that I think there can be no variations
in approach. Rather, I wish merely to simplify the
material available.

CLASSIFICATION

Both Blount1 and Fahey4 have reviewed large
series of fractures of the elbow in children. I have
drawn from those sources for a classification
(Table 1). Their percentage distributions of these
fractures by type are very similar.

ROENTGENOGRAMS IN DIAGNOSIS

With a classification firmly in hand, one can pro-
ceed to roentgenographic interpretation. Roent-
genograms of the elbow can be difficult to inter-
pret. Often the child’s resistance to examination
prevents one from obtaining true anteroposterior
views. Sometimes worthwhile roentgenograms can
be obtained only after induction of anesthesia.
Knowledge of the appearance of epiphyseal cen-
ters for growth and of closure of epiphyseal lines

Dr. Kelly, of the Section cf Orthopedic Surgery at the
Mayo Clinic and Mayo Foundation, read this paper at the
postgraduate conference of the Iowa Chapter, American
Academy of General Practice, at Lake Okoboji, June 22-24,
1961.

is important. However, such data aren’t always
available from memory. A practical source of such
knowledge in a given case is a roentgenogram of
the uninjured elbow.

For reasons of practicality, it is best to consider
the supracondylar and the transcondylar fractures
simply as supracondylar fractures. Separation of
these into different groups is artificial.

ASSESSMENT OF NERVE AND VASCULAR STATUS

On the patient’s arrival for treatment, the vas-
cular and nerve functions in the injured extrem-
ity must be assessed. It goes without saying, of
course, that the child’s general health, the possibil-
ity that there have been accompanying injuries,
and a history of recent food intake must be eval-
uated.

TABLE I

CLASSIFICATION OF FRACTURES OF THE ELBOW

Type Per Cent

Supracondylar fracture (transcondylar) 60

A. Extension type — distal fragment displaced
posteriorly ( Figure I )

B. Reverse or flexion type — distal fragment displaced
anteriorly (rare, less than one per cent of all
supracondylar fractures) (Figure 2)

Fracture of lateral condyle of humerus (Figure 3) . . . . 18
Fracture of medial epicondyle of humerus (Figure 4)

— more than 50 per cent associated with dislocation

of the elbow 8

Fracture of radial neck (Figure 5) 4

Dislocation of the elbow without fracture . 6

Olecranon fracture, Monteggia fractures and rarer

combinations (Figures 5, 6 and 7) 4

100

Journal of Iowa Medical Society

January, 1962

Nerve Injuries. The median, ulnar and radial
nerves all pass the elbow joint on their way to
the hand. It therefore isn’t surprising that all in-
juries of the elbow can be accompanied by in-
juries to those nerves.

Watson-Jones5 states that 15 per cent of supra-
condylar fractures are associated with injury to
the median or the ulnar nerve. In our experience
at the Mayo Clinic, the radial nerve has more
commonly been injured. In a Mayo Clinic series of
108 supracondylar fractures reviewed by Lips-
comb and Burleson,3 the radial nerve had been in-
jured in 11 instances, the median in seven and the
ulnar in three. The lateral condylar fracture isn’t
accompanied by initial nerve injury, but if it is
improperly treated and the condyle fails to unite,
a cubitus valgus results, and there is delayed in-
jury of the ulnar nerve years later. The uncom-
mon reverse or flexion supracondylar fracture is
accompanied by ulnar-nerve injury in a high per-
centage of cases. Fracture of the medial epicon-
dyle may be associated with injuries of the ulnar
nerve. In fracture of the radial neck or in Mon-
teggia fracture with posterior displacement of the
radial head, injury to the posterior interosseous
branch of the radial nerve may occur.

As a rule, these are contusions or traction in-
juries of the nerves. Continuity of the nerves isn’t
interrupted. For this reason, the nerve injuries are
temporary and clear up in a matter of weeks.
Therefore, except for certain injuries of the ulnar
nerve associated with dislocation of the elbow and
fracture of the medial epicondyle, exploration of
the nerve is not justified primarily.

Vascular Injuries. Arterial injury in fracture of
the elbow, particularly in supracondylar fracture,
is especially troublesome. In Lipscomb and Burle-
son’s series,3 22 per cent of 108 supracondylar frac-
tures were associated with either vascular or
neural complications.

Vascular injury is most likely in supracondylar
fracture or, as its clinical manifestation is more
commonly called, in Volkmann’s ischemic contrac-
ture. Probably the fracture itself causes lacera-
tion, contusion with spasm, or thrombosis of the
brachial artery. Certainly tight bandages, faulty
casts and repeated manipulations may tip the
scales in a situation where the circulation has
been compromised. The point is that vascular in-
jury as well as neural injury is best diagnosed
before treatment is started.

The classic signs of vascular injury are pain,
paralysis and pallor. Absence of the radial pulse
per se isn’t a sign of vascular injury if color and
temperature of the fingers are normal. Nonethe-
less, absence of the radial pulse should alert one
to the necessity of giving careful scrutiny to the
situation. Signs of arterial injury may not all be
immediately evident. For this reason, careful ob-
servation following manipulation is important. Al-
so, if the child has excessive pain after a proper
reduction, one must strongly consider the possibil-

Figure I. Views a and b show a markedly displaced ex-
tension-type supracondylar fracture. The distal fragment is
displaced posteriorly. Views c and d show the elbow two
years later. The fracture has healed with no deformity.

ity of impending Volkmann’s ischemic contrac-
ture.

After proper roentgenographic evaluation and
proper assessment of nerve and vascular con-
tinuity, one can proceed with treatment. The
child’s general condition must be such as to per-
mit general anesthesia, if treatment is to be given.

Vol. LII, No. 1

Journal of Iowa Medical Society

Figure 2. Picture a shows a rare flexion type or reverse supracondylar fracture. The distal fragment is displaced anteriorly. Pic-
tures b and c were taken seven months later. Healing is evident, alignment is acceptable and function is good.

If general anesthesia is contraindicated, reduction
can be delayed, provided that nerve or vascular
injury is not present. However, axillary brachial
block can be used. In fact, it is used routinely
for all such fractures by some.0

REDUCTION OF SUPRACONDYLAR (TRANSCONDYLAR)

FRACTURES OF THE EXTENSION TYPE (FIGURE I)

Gentle, steady traction on the supinated hand is
maintained for five minutes. The thumb of the
other hand palpates the distal portion of the prox-
imal fragment and disengages the fracture. Vary-
ing supination will correct the rotation. Lateral
displacement is corrected by molding the fracture
with the palms of the hands before flexing the el-
bow. After the correction of rotation and lateral
displacement, the elbow is flexed to 45 degrees
with the forearm pronated. The radial pulse
should be checked, and if it is palpable, then a
posterior padded plaster splint is applied to main-
tain position. One avoids the use of an encircling
bandage at the elbow.

If the radial pulse disappears upon flexion to 45
degrees, one is justified in observing the patient
for a short period (20 to 30 minutes), since pulsa-
tion often returns. If there is any sign of ischemia,
however, such as pallor or cyanosis of the fingers,
or poor return of color on blanching of the nail-
beds, then the elbow is released and brought back
to a position that permits the radial pulse to re-
turn. In my experience, if the elbow cannot be
maintained at 45 degrees of flexion, a reduction
will not be maintained. If there is any question
regarding the adequacy of the circulation, one is
well advised to resort to one of the methods of
lateral traction. Certainly the simplest is Dunlop
traction.

Dunlop traction1 is used as follows. Moleskin

traction tapes are applied to the forearm, with the
patient supine and the elbow at 120 degrees.
Countertraction is applied by means of a wide
sling of felt placed on the distal part of the arm.
Care must be used not to apply excessive weight,
for this can be injurious to the circulation. Often
traction accomplishes the reduction, and it can be
helped, if necessary, by gentle manipulation at the
bedside.

The patient can be left in traction for three
weeks, and then the arm may be placed in a sling,
or after the danger of vascular insufficiency has
passed, the elbow may be brought to flexion and
immobilized as described above.

MANAGEMENT OF SUPRACONDYLAR FRACTURE WITH
VASCULAR INJURY

Vascular injury (Volkmann’s ischemic contrac-
ture) may be apparent before, at the time of, or
after reduction. The signs of impending Volk-
mann’s contracture have been described above.
Institution of Dunlop traction is the first step. A
sympathetic nerve block may be tried. If im-
mediate results aren’t obtained, then the cubital
fossa is explored at once. A delay of three or four
hours can be disastrous.

Resection of the torn, thrombosed or spastic
segment of brachial artery allows the abundant
collateral circulation to be released from spasm.3
Lipscomb has said that it is much better to err on
the side of exploring the cubital fossa and finding
a normal brachial artery, than to hope that the
situation will improve with watchful waiting.

Care of the fracture is secondary. However, one
can either reduce the fracture at the time of ex-
ploration and hold it in reduction with crossed
Kirschner wires, or use Dunlop traction to main-
tain reduction.

Journal of Iowa Medical Society

January, 1962

SUPRACONDYLAR FRACTURE OF THE FLEXION OR
REVERSE TYPE (FIGURE 2)

Supracondylar fracture of the flexion or reverse
type is rare. Since the distal fragment is anterior,
or flexed on the proximal fragment (Figure 2a),
reduction is obtained by extension. Immobilization
of the fracture in extension usually allows an ac-
ceptable reduction. It is probably safest after three
weeks to bring the elbow to a right-angle position.
I have seen one case in which immobilization in
full extension resulted in considerable permanent
loss of flexion of the elbow.

FRACTURE OF THE LATERAL CONDYLE (FIGURE 3)

Fracture of the lateral condyle with displace-
ment almost invariably requires operative treat-
ment. In some instances the fragment may be un-
displaced or only minimally displaced, and can be
treated by manipulation and plaster immobiliza-
tion, with the elbow at a right angle (90 degrees)
and with the forearm pronated. As Fahey4 has
pointed out, if this course is followed, roentgeno-
grams must be taken twice during the first 10-day
period following injury to make sure the frag-
ment doesn’t become displaced. Certainly in all
fractures with displacement, open reduction
through a lateral incision is necessary, with main-
tenance of reduction by means of threaded Kirsch-
ner wires (Figure 3b). Faulty reduction leads to
nonunion, with resultant exaggerated carrying
angle, and in later years leads to a tardy ulnar
palsy due to the stretch placed on the ulnar nerve
by the abnormal position of the elbow.

Figure 3. View a shows a typical fracture of the lateral
condyle, with marked rotation and displacement. View b
shows the fracture reduced and held with Kirschner wires.
( Kirschner wires are cut off so that they lie subcutaneously.)

FRACTURE OF THE MEDIAL EPICONDYLE (FIGURE 4)

In Fahey’s experience, fracture of the medial
epicondyle has been complicated by dislocation of
the elbow in more than half the cases. The con-
sensus is that if the epicondylar fragment is in-
carcerated in the joint, or if signs of ulnar-nerve
irritation are present, it is best to explore the frac-
ture. The rationale of this approach is that one
had better remove the epicondylar fragment from

Figure 4. View a shows fracture of medial epicondyle with only slight displacement. This often can be treated by immobiliza-
tion in flexion. Union may be only by fibrous tissue. View b shows a fracture of the medial epicondyle with displacement. Ul-
nar-nerve symptoms were present. Clinical examination indicated spontaneous reduction of the dislocation. View c shows the
medial epicondyle replaced and fixed. The ulnar nerve was inspected to make sure it had not been caught in the joint.

Vol. LII, No. 1

Journal of Iowa Medical Society

Figure 5. Pictures a and b show a fracture of the radial neck, with an associated fracture of the olecranon. With this degree
of radial-head tilt and no improvement on closed manipulation, it is best to reduce the fracture by open surgical methods. In
picture c, the fracture of the radial neck and the olecranon fracture have been reduced and are held by Kirschner wires. It was
thought best to use internal fixation because of the instability of these fractures.

the joint under direct vision than try to do it by
manipulation. Also, in a few cases, the ulnar nerve
has been pulled into the joint with the fragment of
bone, and gentle removal under direct vision is
best. This situation probably represents one of the
exceptions to the usual rule that nerve injury
need not be explored primarily in fracture of the
elbow. If the epicondyle is only minimally dis-
placed, immobilization in flexion for three weeks
is all that is necessary (Figure 4a). Healing of the
fragment may be by fibrous union rather than by
bony union, but the result isn’t hindered. Blount1
has said that if the epicondyle is moderately dis-
placed, even without ulnar-nerve signs or incar-
ceration in the joint, it is best to replace it in the
fractured bed and hold it with Kirschner wires
(Figure 4b). Often the dislocation is temporary
and reduces itself spontaneously. Consequently,
the actual joint injury is more serious than it ap-
pears, and it is wise to warn the child’s family
that joint motion will return slowly and that some-
times permanent limitation of motion may result.

FRACTURE OF THE NECK OF THE RADIUS

In contrast to the adult, the child fractures the
neck and not the head of the radius. Also, in fur-
ther contrast, fracture of the radial neck in a child
must never be treated by excision of the radial
head. The consequences of such an act are radial
shortening, clubhand and a permanently weak el-

bow. Some such cases can be treated by closed
manipulation with firm pressure on the radial
head and with the elbow extended and abducted.
Blount1 has said that in the young child, angula-
tion of less than 45 degrees can be accepted with-
out resort to open operation. Fahey4 has observed
that angulation of more than 25 degrees which
cannot be improved by manipulation should be re-
duced under direct vision. Usually the choice is
not that critical, and in my experience the angula-
tion usually corrects to an acceptable 25 or 30 de-
grees, or the fragment is so severely angulated
or completely displaced that reduction under di-
rect vision is necessary (Figure 5a). Fixation with
Kirschner wires is generally unnecessary unless
there is some instability such as may occur if
there is an associated fracture of the ulna (Figure
5b.)

MISCELLANEOUS FRACTURES OF THE ELBOW

Fracture of the olecranon process as a single in-
jury isn’t common. It responds well to closed re-
duction in an extended position. Association of
olecranon fracture with fracture of the radial neck
occurs more often, and may well require open re-
duction if the fracture of the radial neck demands
it (Figure 5). Monteggia fractures in children are
usually amenable to closed reduction, and in that
respect are very different from such fractures in
adults (Figure 6). In some instances, if a severe-
ly displaced fracture of the radial neck is seen.

Journal of Iowa Medical Society

January, 1962

Figure 6. Monteggia fracture with posterior displacement
of the radial head and fracture of the ulna. This fracture
was reduced by closed manipulation alone. Pictures a and b
were taken prior to reduction. Picture c was taken six weeks
after reduction.

rather than dislocation of the radial head, one may
have to resort to open surgical methods (Figure

7).

DISLOCATION OF THE ELBOW

Dislocation of the elbow isn’t a common injury
in children. Fahey4 noted it in two per cent of his
series of elbow injuries, and Blount1 in six per
cent. It is treated by gentle reduction and im-
mobilization in flexion. It is more commonly seen
in association with fracture of the medial epicon-
dyle than as a separate injury.

Subluxation of the radial head, or nursemaid’s
elbow, is frequently observed in children less than
five years of age. Usually the elbow is held in
flexion and the forearm in pronation. Roentgeno-
grams aren’t helpful. The diagnosis is a clinical
one. Often, spontaneous reduction occurs during
the process of obtaining roentgenograms. If not,
reduction is obtained by quick supination of the
forearm.

COMMENT

I have tried to emphasize the important points
in the management of elbow injuries in children.
This presentation can be considered only as an in-
troduction to the problem. Factors in causation of
altered carrying angles in supracondylar fractures
haven’t been discussed, and there is no unanimity
of opinion regarding them. Fahey4 has expressed
the view that tilting or lateral angulation of the
lower fragment is the major cause. Suffice it to say
that although offset of the fragments can be ac-
cepted on the lateral view, proper alignment on
the anteroposterior view is important in prevent-

Figure 7. View a shows a type of Monteggia fracture. It
differs from the usual fracture of this type in that the radial
neck has fractured and the head is displaced. View b was
taken postoperativeiy. Because the radial head was marked-
ly displaced it had to be reduced by ooen operation. The
ulna was fixed with an intramedullary Steinmann pin.

ing this disagreeable complication.

One always is asked, “How long do you im-
mobilize the fracture?” Facetiously, one might re-
ply, “Until it has healed.” As a rule, for nearly
all elbow fractures, after four weeks the extremity
can be placed in a sling, and the child can begin to
limber up the elbow on his own. After five weeks,
external support is usually unnecessary.

One final point is worthy of emphasis. Physical
therapy to limber up the elbow is not only un-
necessary but actually contraindicated. Having the
child carry pails of sand or tug away at his elbow
not only is useless but actually will cause limita-
tion of motion. Instead, the child should be permit-
ted to limber up the elbow on his own.

REFERENCES

1. Blount, W. P.: Fractures in Children. Baltimore, The
Williams & Wilkins Company, 1954.

2. Conventry, M. B., and Henderson, C. C.: Supracondylar
fractures of humerus: 49 cases in children. Rocky Mountain
M. J„ 53:458-465, (May) 1956.

3. Lipscomb, P. R., and Burleson, R. J.: Vascular and neu-
ral complications in supracondylar fractures of humerus in
children. J. Bone & Joint Surg., 3 7A:487-492, (June) 1955.

4. Fahey, J. J.: “Fractures of the Elbow in Children,” In:
Reynolds, F. C.: Instructional Course Lectures of the Amer-
ican Academy of Orthopaedic Surgery. St. Louis, The C. V.
Mosbv Company, 1960, pp. 13-46.

5. Watson-Jones, Reginald: Fractures and Joint Injuries,
Fourth Edition. Baltimore, The Williams & Wilkins Company,
1952, Vol. I, pp. Ill, 131, 136-138.

6. Clayton, M. L., and Turner, D. A.: Upper arm block
anesthesia in children with fractures. J.A.M.A., 169:327-329,
(Jan. 24) 1959.

Open Fractures

FRED REYNOLDS, M.D.
St. Louis, Missouri

The compound or open fracture dates from the
dawn of time, and its management dates from the
beginning of medical history. Isn’t it strange, in
this enlightened era, that a problem of such mag-
nitude which has been around so long isn’t yet
generally understood, and that its correction hasn’t
yet been standardized? The fact remains, how-
ever, that strong differences of opinion exist re-
garding many aspects of the management of these
injuries, even among the most learned physicians.

Based on what I observe continually in my own
locality, it seems safe for me to say that utter con-
fusion must be the state of mind of the average
physicians who are called upon to treat the ever
increasing numbers of open fractures. One won-
ders whether in all of medicine there is a condi-
tion that is, on the average, managed so poorly as
is trauma. Yet, satisfactory results can be and are
being obtained by those who adhere to a few
fundamental principles which I shall try to point
out.

TREATMENT IN THE EMERGENCY ROOM

Rarely does a physician have an opportunity to
start the treatment of open fractures at the scene
of the accident, and since the principles employed
when the patient is first seen in the hospital
emergency room are essentially the same as those
that would be employed at the accident scene, I
shall not discuss treatment at the place where the
injury was incurred.

In the emergency room, the physician’s first and
most important step is to check the patency of
the airway and to establish an adequate airway
if respiration has been embarrassed. His second
step is to control hemorrhage, and his third is to
treat shock. To establish the airway, it may be
necessary to occlude a sucking wound of the
chest by means of a bandage, or to stabilize the
chest with Towell clip traction, or to carry out a
tracheotomy. At any rate, it is of the utmost im-
portance that an airway be established and main-
tained. Hemorrhage can usually be controlled by
means of pressure dressings. Rarely is it neces-

Dr. Reynolds is a professor of orthopedic surgery at the
Washington University Medical School, and he made this
presentation at the 1961 annual meeting of the Iowa Medical
Society.

sary to apply a tourniquet, and if the patient ar-
rives at the hospital with a tourniquet, it should
be immediately released. At times, it is possible
to clamp one or more small arteries that are vis-
ible in the wound. A needle is immediately placed
in a vein at a convenient location, blood is drawn
for typing and cross-matching, a hematocrit de-
termination may be helpful, and intravenous fluids
are started. Normal saline is best at this stage.

When the airway has been established, hemor-
rhage controlled and fluid balance on the way to
restoration, the next step is to obtain all informa-
tion possible concerning the mechanism of the
injury. The history can be obtained from the pa-
tient if he is conscious, but otherwise such in-
formation as can be gathered from witnesses may
be quite helpful. A careful and complete physical
examination must then be carried out, and one
should work from the known to the unknown. Tire
open fractures are obvious, and it is important to
assess the entire extent of injury to other bones
and joints, and then to determine the status of
the blood vessels and nerves in the involved ex-
tremities. When this survey has been completed,
sterile pressure dressings should be applied to the
wounds. I see no objection whatever to the in-
stillation of local antibiotics in the wounds. The
injured extremities are then immobilized in ap-
propriate splints.

Medication for pain, the instigation of antibiotic
therapy and immunization against tetanus should
also be commenced in the emergency room. One
should bear in mind, of course, that it is unwise
to give morphine to patients who have been un-
conscious or who are in profound shock. In all
probability, the best antibiotic to administer is
penicillin. If the patient has had previous active
immunization, a booster injection of tetanus toxoid
is given. If he has not had any previous active
immunization, tetanus antitoxin, 3,000 to 5,000
units, should be administered following appropri-
ate skin testing. If the wounds are extensive and
it seems likely that there will be repeated in-
strumentation, it probably is also advisable to
start active immunization at this time, and one
should bear in mind that the response to active
immunization will be influenced by the amount
of tetanus antitoxin administered.

REFERRAL MUST BE PROMPT!

At this stage, the physician has brought the pa-
tient under control. There is an airway, bleeding
has been controlled, the wounds have been dressed,

Journal of Iowa Medical Society

January, 1962

the fractures have been immobilized, and the pa-
tient is receiving treatment for shock and for
pain. The physician by this time has a pretty clear
idea of the extent of injury, and he must now de-
cide whether the institution to which the patient
was brought is properly equipped to provide the
indicated care, and whether his own experience
or that of the other available staff members is
such that the entire extent of the patient’s injuries
can be promptly and efficiently handled. If the in-
stitution isn’t adequately prepared for the total
management of the patient, or if the physicians
practicing there are inadequately trained in the
procedures that must be done, the patient should
be transferred at this time to the nearest hospital
where definitive treatment can be carried out.

Under no circumstances should wounds be closed
while the patient is awaiting transfer. Likewise,
it is a waste of time and a cause of considerable
discomfort to the patient to have x-rays taken,
unless the films are to accompany the patient.

Promptness in transferring patients is so impor-
tant that I shall repeat what I have just said: It
is imperative that you decide at this time whether
the patient is to be transferred elsewhere. He
should not be kept for one or two days and then
transferred after partial therapy has been insti-
gated. This single error accounts for many of the
poor results associated with the management of
open fractures. All too frequently, a patient with
open injuries is moved to a center for definitive
treatment several days following the accident,
and in the interim his wounds have been closed
after an inadequate debridement and without
prompt and competent vascular repair. I cannot
overemphasize the importance of your arriving
at an early decision regarding transfer. If the
patient is to be kept, then treat him! If you aren’t
going to be able to treat all of his injuries com-
pletely, then don’t keep him!

AVOID HANDLING THE PATIENT TOO MUCH

If the patient is to remain at the institution
where he was first brought, we have now reached
the stage at which x-rays may be obtained. At
this point, it is worthwhile recounting what hap-
pens to the patient even in many of our best hos-
pitals. Bear in mind that the patient has been in
an accident: he has been picked up at the scene
of the accident; he has been put into a conveyance
and has been carried to the hospital. As a rule,
when he arrives at the hospital he is moved from
the conveyance onto a litter or examining table.
When his condition has stabilized and he is ready
to leave the examining room, he usually is moved
back onto a stretcher and taken to the x-ray de-
partment. There, more often than not, he is moved
from the stretcher onto the x-ray table. Some-
times the radiologists, being anxious to get good
and 1 epresentative films, have been guilty of re-
moving splints or even of pushing and pulling

the fractured extremities — all to the discomfort
and possible injury of the patient.

Once the x-rays have been obtained, the patient
is moved back from the x-ray table onto a stretch-
er, on which he is then carried from the x-ray
department to his hospital bed. There he is again
moved, from the stretcher to the bed. Then he is
prepared for anesthesia, and when ready is again
moved from the bed to the stretcher, transported
to the operating room, and there moved from the
stretcher to the operating table. Although all of
this may sound ridiculous, it more frequently
than not accords with the actual circumstances in
the management of such patients. Is it any wonder,
then, that the patient arrives in the operating
room in a state of shock? As a matter of fact, he
has to be pretty rugged to get there at all!

When the patient comes into the hospital, he
should be placed upon a stretcher that he can re-
main upon throughout all of his travel. The
Transaver stretcher is such a vehicle. Complete
resuscitation and immobilization can be carried out
in the emergency room without the patient’s being
removed from this stretcher. He can then be taken
to the x-ray department, and since this stretcher
will go over an ordinary x-ray table, the films can
be taken through it. He can then remain on the
stretcher while he is being prepared for surgery,
and all definitive surgery that doesn’t require an
overhead frame for skeletal traction can be car-
ried out upon the stretcher. Thus, the patient need
not be moved until the surgical procedures have
been completed. This type of management will fa-
cilitate the comfort of the patient and benefit his
general condition.

DEBRIDEMENT MUST BE THOROUGH

X-rays have now been obtained to confirm the
diagnosis and to reveal the peculiarities of the
various fractures. Therapy is next. It must always
be remembered that treatment of open fractures
is treatment of the wound. If one fails in treating
the wound, then he fails in treating the fracture,
irrespective of how beautifully it may have been
reduced. The proper treatment, then, is the treat-
ment of the wound, and the fracture should be ig-
nored unless it is important to treat the fracture
to facilitate wound healing.

Proper treatment of the wound means complete,
adequate and thorough debridement. It is ideal,
when possible, to carry out this debridement with-
in six hours of the accident, when most of the
organisms that have contaminated the wound re-
main as contaminants and haven’t yet begun to
multiply and to start an infection. However, the
debridement should be carried out even though
the patient is seen and readied for surgery at a
much later time. The only open fractures in which
it is permissible to treat the fracture without de-
bridement are those in which the fractured bone
has penetrated the skin in a very small area, and

Vol. LII, No. 1

Journal of Iowa Medical Society

Figure I. The top picture shows an open fracture of the leg. The extent of the wound suggests only moderate soft-tissue dam-
age. The bottom picture was taken at the time of debridement, after the entire extent of the damaged area had been opened
and all d amaged and devitalized tissue removed.

volved extremity and to make traction so that
further soft-tissue damage is avoided. A sterile
dressing is kept over the wound, the surrounding
area of the extremity is shaved and scrubbed
thoroughly with soap and water and cleansed with
ether, and then the area is prepared with iodine
and alcohol up to the margins of the wound. In
wounds where there has been a considerable soft-
tissue and skin loss, and where there is some
ground-in dirt, it may be advisable to scrub the
open wound with soap and water, too, but it
should not be prepared with iodine or alcohol.
The wound is then thoroughly irrigated with
Ringer’s solution, an attempt being made to wash
material from the depth of the wound to the out-
side. After the wound has been irrigated thorough-
ly and cleansed as much as possible in this way,
sterile drapes are applied, and the debridement is
commenced.

It is necessary, as a rule, to excise a very thin
edge of damaged skin. The wound is enlarged in
a longitudinal fashion so that it will be possible
to open fascia and muscle planes throughout the
entire damaged area, conserving as much skin
and viable tissue as possible. The purpose of de-
bridement is to remove all damaged, devitalized

in which it seems that there is unlikely to be
much soft-tissue damage beneath. A decision in
this regard demands a great deal of skill and
surgical judgment. The other possible exception
is in injuries produced by small-arms fire of low
velocity, in which there is a small wound of
entry and, perhaps, an equally small wound of
exit. All other open fractures must have debride-
ment.

This debridement must be carefully planned,
and the patient must be readied for surgery. This
means that the patient must have recovered from
shock, the major portion of the blood loss must
have been restored, the patient must have an
empty stomach, and he must have received ap-
propriate pre-anesthesia medication. The nasal
tube is useless in attempting to empty the stomach,
and the best way to assure an empty stomach is
to force the patient to vomit. If the patient’s gen-
eral condition or his injuries contraindicate vomit-
ing, then a skilled anesthetist may be able to pass
an endotracheal tube to prevent aspiration, or it
may be possible to carry out the debridement
under spinal or regional block anesthesia.

The technic of the debridement, once the pa-
tient has been anesthetized, is to support the in-

Journal of Iowa Medical Society

January, 1962

tissue and all foreign substances. It is mandatory
that the entire remote recesses of the injured area
be exposed to clear vision, so that one can be
sure that all devitalized tissue and foreign sub-
stances have been removed. Where there is a
likelihood of excessive blood loss, debridement
may be done under a tourniquet. However, in
most instances it is inadvisable to use a tourniquet,
for it is harder to judge viable and non- viable
structures when the circulation has been cut off.
When one is debriding certain areas, such as the
hand, a tourniquet perhaps is always advisable.
Small — pea-size and smaller — pieces of bone that
are completely detached from soft tissue and are
contaminated can perhaps be removed, except in
those circumstances where there are large num-
bers of such small-sized pieces, the removal of all
of which would create a gap in the fracture. Large
pieces of bone, though they may have been de-
tached from soft tissue and contaminated, should
be cleansed and replaced.

Severed nerves may be brought together with
an identifying stitch, preferably of fine wire, but
should not be repaired. The same is true of severed
tendons. Severed major vessels must be repaired
either by suture or by graft. In all instances in
which a major vessel has been damaged and has
been repaired, it is mandatory that the fracture
be stabilized by internal fixation.

The entire extent of the wound is now known
and it has been thoroughly cleansed. All devital-
ized tissue has been removed, and all foreign
bodies have been removed. The next questions be-
fore the surgeon are what to do about the fracture
and whether the wound should be closed or left
open.

INTERNAL FIXATION SHOULD BE AVOIDED
WHERE POSSIBLE

The fracture should be stabilized, as I have said,
when any major arterial repair has been accom-
plished. Certain injuries in which the soft-tissue
involvement has been extensive, and in many of
which there will need to be secondary procedures
such as skin grafts and flaps, will heal more satis-
factorily if the fractures are stabilized by internal
fixation. In all circumstances where the treatment
of the wound doesn’t demand rigidity of the bony
framework, no internal fixation is indicated. When
internal fixation is indicated, however, intra-
medullary fixation should be employed whenever
possible. One must remember that a fracture cre-
ates an area of dead bone, and when the fracture

surfaces are brought together by a reduction,
either open or closed, two areas of dead bone are
reapposed. This fracture doesn’t heal as a result
of the outgrowth of bone from one end to the
other. Rather, it occurs first by a bridging of that
area and later by the destruction and replacement
of the areas of dead bone which have lost their
blood supply during the trauma of fracture. The
more extensive the injury, and the greater the
amount of stripping of soft tissue and loss of blood
supply, the greater the area of dead bone and
the greater the chance of delayed union or non-
union. Therefore, any procedures that are carried
out at the same time as the debridement for inter-
nal fixation of bone have the effect of increasing
the amount of bone death and, if anything, of
opening up new pathways for infection. Internal
fixation must therefore be avoided whenever pos-
sible.

USUALLY IT IS PREFERABLE TO LEAVE
THE WOUND OPEN

The question of whether a wound should be
closed or left open is one that only a skilled sur-
geon should answer. In general, however, one can
say that if the patient has been readied for de-
bridement within six hours following his injury,
if a fair and accurate debridement has been car-
ried out, if the surgeon is convinced that all dam-
aged, devitalized tissue and foreign matter has
been removed, and if the edges of the wound can
be brought together without tension, it may be
feasible to sew it up. However, in every instance
the safest procedure to follow is to drain the wound
lightly with fine mesh gauze. Personally, I prefer
fine mesh gauze soaked in glycerine. No harm
can come from leaving the wound open, and if
proper debridement has been carried out and if
the patient is properly managed, one should be
able to close it in five to seven days by delayed
suture, or by a combination of delayed suture and
skin graft.

If the treatment of the wound has been success-
ful, the injury has been converted to a closed
fracture, and any adjustment in the fracture that
becomes necessary mav be done at the end of
approximately four weeks from the time of wound
healing. Following debridement, the patient may
be treated in skeletal traction or (depending upon
the nature and location of the fracture) in a plas-
ter cast. Under no circumstances should non-
padded plaster casts be used, and unless a highly
competent team of house officers is available, the

Figure 2. The top photograph shows an open fracture of both bones of the leg as it appeared on the patient's arrival at our
hospital, seven days after injury. An inadequate debridement had been followed by wound closure. At this stage, the physician
advised the patient to undergo an amputation. The middle photograph shows the appearance of the leg one week fo'lowing rad-
ical debridement. The patient was then no longer septic. The bottom picture shows the appearance of the leg following closure
of the wound by split-thickness skin grafts.

Vol. LII, No. 1

Journal of Iowa Medical Society

January, 1962

plaster cast should be split before the patient
leaves the operating room.

POSTOPERATIVE CARE

In the postoperative period, antibiotics are con-
tinued. In all probability the major benefit that
antibiotics can confer in open fracture cases has
been rendered during the first 24 hours. How-
ever, it is customary to continue antibiotics for
the next two or three days. Continuing them past
that stage is inadvisable unless there is evidence
of infection.

It is of utmost importance that the patient be

Figure 3. The top two photographs at the left show an
open fracture of the tibia with extensive soft-tissue damage
treated by inadequate debridement and closure of the wounds.
At that time, three days postoperatively, foul-smelling gas
was bubbling out of the wound over the tibia. The bottom
picture at the left shows the extent of the damage after
thorough debridement. The picture above and at the right
shows the thigh wound after removal of all dead tissue.
Surgery, blood and antibiotics relieved the toxicity, and the
wound was then closed by means of skin grafts.

observed closely during the postoperative period.
Pain must be carefully evaluated. Continuing pain
or pain that begins during the postoperative pe-
riod, if it is of greater degree than the physician
would anticipate from the particular injury, prob-
ably indicates that the patient is in trouble. Either
there has been a fresh and unusual hemorrhage,
or there is infection.

In almost every case of trauma, there will be
an elevated temperature and pulse rate during
the first 24 to 36 hours. This is anticipated and
doesn’t indicate wound difficulty. However, a
rapid pulse, plus pain occurring on the second or
third postoperative day, without temperature ele-
vation but with the patient anxious and pale,
suggests a clostridial infection. One can’t wait
until there is evidence of air in the tissues associ-
ated with black gangrene surrounding the wound,
or a foul odor. One must be alert to the possibili-
ties, and a clinical picture of pallor, anxiety, per-
haps sweating, a rapid pulse— more rapid than

Vol. LII, No. 1

Journal of Iowa Medical Society

the patient’s temperature justifies— and an unusual
amount of pain demand careful inspection of all
wounds in the operating room under good light.
If the wounds have been closed, they must be
opened; if they have not, their inspection is fa-
cilitated.

The diagnosis of gas gangrene at this stage is
clinical. Inspection with a good light should re-
veal the area of muscle or soft tissue involved.
Early diagnosis makes it possible to resect the
involved area and often to spare the extremity.
If a diagnosis is delayed until there is widespread
gas in the soft tissue, foul odor and gangrenous
areas on the skin, the extremity or perhaps even
the patient’s life has been lost!

Gas gangrene antitoxin is ineffectual in this
condition and should not be used. Surgery and
penicillin, plus adequate blood replacement, con-
stitute the treatment.

Although infection with clostridial organisms is
dramatic, it isn’t so common as is infection with
ordinary pyogenic bacteria. Pain, swelling and
fever in any wound patient demand inspection of
the wound. And again, the treatment is surgical
drainage plus antibiotics.

Open fractures, like open reductions, are associ-
ated with a higher percentage of delayed unions
and non-unions than are closed fractures. How-
ever, once one has successfully converted the
open fracture to a closed one, he can carry out
any reconstructive procedure necessary to re-

store the extremity to maximum function. No
instrumentation or manipulative procedure should
be carried out until the wound has thoroughly
healed. This usually takes three to four weeks.
Each such procedure should be preceded by anti-
biotic therapy. Remember that reconstructive pro-
cedures on bones and joints are almost always
possible when the wounds have been properly
treated and have healed, whereas the end result
of failure in wound treatment is often amputation
or even loss of life itself.

Adherence to the procedures that I have out-
lined will result in wound healing in the majority
of instances. However, even under the best cir-
cumstances it is sometimes impossible to close
the wound before infection occurs, and failure of
wound treatment results. In those cases, thorough
drainage, immobilization, antibiotics and blood
replacement will be adequate to relieve the pa-
tient of toxicity and will localize the inflammatory
process. If plates, screws, wires, etc. have been
used to stabilize the fracture, they must be re-
moved. However, if an intramedullary nail is in
place, it should not be removed. In most in-
stances the above treatment will allow localiza-
tion of the infection to the fracture site. The
problem then is one of localized osteomyelitis. One
must remember that any open wound is an in-
fected wound, in that it harbors organisms that
will interfere with reconstructive procedures.

Treatment for Glaucoma

In a study reported by Ballintine and Garner,*
in the September, 1961, issue of archives of oph-
thalmology, 70 eyes were uncontrolled in that
either the intraocular pressure was high (>21)
or the coefficient of outflow was low ( < .18 ) while
the eye was receiving the maximum tolerated
medical therapy.

“In each case when epinephrine therapy was
begun it was administered as the 2 per cent so-
lution [Glaucon], one or two drops in the con-
junctival cul-de-sac once or twice daily. The pre-
vious medical program was unchanged. When im-
provement in coefficient was noted (i.e., when the
coefficient became >.18), the amount of medical
therapy was gradually reduced. In many patients,
after several months, the coefficient of outflow and
intraocular pressure became normal.”

The authors went on to say: “Intraocular pres-
sure was controlled, that is, always less than 22
mm. Hg, in 58 of the eyes (83 per cent), and un-

* Ballintine, E. J., and Garner, L. L.: Improvement of
coefficient of outflow in glaucomatous eyes: prolonged local
treatment with epinephrine, arch. ophth., 66:314-317, (Sept.)

controlled despite prolonged maximum therapy
in 12 eyes (17 per cent). Of these 58 eyes in
which the intraocular pressure was controlled fol-
lowing the instillation of epinephrine, the co-
efficient improved in 49 eyes (70 per cent). The
coefficient was recorded as having been improved
when it became greater than 0.12 and 50 per cent
greater than it had been prior to the institution
of epinephrine therapy.”

The improvement of coefficient was subsequent-
ly lost in 10 eyes. Glaucon therapy of seven eyes
had to be discontinued because of local allergy.
In addition, the eyes of one patient burned in-
tolerably, and therapy had to be discontinued for
that reason.

So far as the authors are aware, this is the first
instance that an anti-glaucomatous agent has been
shown to improve the coefficient of outflow during
prolonged therapy. With miotic therapy, improve-
ments in coefficient are gradually lost, even with
increased dosage. Two per cent epinephrine per-
mits reduction of miotic and carbonic anhydrase
inhibitors while maintaining the high coefficient
of outflow.

Use of Nylon Lace-Mesh

In Fixation of Split-Thickness Skin Grafts

WILLIAM STANFORD, M.D.

JOHN E. HUTCHINSON, M.D., and
SIDNEY E. ZIFFREN, M.D., Iowa City

Major hazards contributing to loss of grafts in
split-thickness skin grafting processes are infec-
tion, excessive wound drainage, and inadequate
immobilization. The use of a material for graft
fixation which allows for constant visualization
and at the same time provides a means for con-
trolling drainage and infection is, therefore, highly
desirable. Incorporation of the above principles in
the method of fixation allows earlier grafting in
cases of acute trauma and potential infection, and
minimizes losses in the regrafting of old burns
and old indolent wounds. A lace-mesh fixation
technic has been described by Shea et al.,1 advo-
cating the use of an impregnated rayon mesh, and
by Freeman,2 advocating nylon or dacron wide
mesh net. A method employing nylon lace-mesh
(Figure 1) is described below. This economical
method largely fulfills the critera that have been
enumerated, by providing for adequate fixation
and for evacuation of transudates and exudates
from the graft site.

MATERIALS

Parresined lace-mesh dressing (Abbott) was oc-
casionally used to immobilize grafts at University
Hospitals, Iowa City. However, the method was ex-
pensive and could be used only in relatively small
areas. In an attempt to find a substitute, since
this material is no longer manufactured, one of us
(J. E. H.) introduced inexpensive nylon lace-mesh
or netting. The material comes in large bolts and
sells for 59 cents per yard. It can be obtained in
department stores, and is the same material as
that used in dresses for women.

Experimental studies disclosed that the nylon
can withstand autoclaving for 20 minutes at 250 °F.
and 20 lbs. pressure. In addition, overnight immer-
sion in 1:1,000 aqueous Zephiran solution and 70
per cent isopropyl alcohol does not affect it. The
material is of sufficient tensile strength to hold

The authors are staff members in the Department of Sur-
gery at the S.U.I. College of Medicine.

grafts in place, and pliable enough to mold well
in difficult areas such as the neck, axilla and but-
tock. The thread count is 22/23 per square inch,
and the material is 40 denier, dorn type nylon.
Mesh of this thread count and denier provides
openings of sufficient size to allow evacuation of
retained secretions without the plugging that is
characteristic of finer-mesh dressings.

TECHNIC

Fixation is accomplished by spraying the over-
lapping mesh on skin with Aeroplast,* after hav-
ing taken care to cover the area over the grafts
with sponges. Additional fixation was originally
accomplished by circumferential silk tacking su-

Figure I. Small piece ol nylon lace-mesh.

Vol. LII, No. 1

Journal of Iowa Medical Society

tures, but the Aeroplast alone proved satisfactory,
and silk is no longer used.

Circumferential extremity burns are treated by
fixation above and below with Aeroplast. The free
edges are then approximated with running silk to
form a cylinder. In other areas such as the axilla
and buttock, it is necessary to cut a “V” in the
material so that it will mold to the particular con-
tour desired.

Immobilization is achieved primarily through
the patient’s cooperation, but when the patient has
been a child or the wound has been a circumfer-
ential one of an extremity, casts and splints have
been applied.

POSTOPERATIVE CARE

The usual procedure after grafting and im-
mobilization is to apply saline-moistened sponges
over the grafted area. These are changed by the
nursing staff every two to four hours. Daily, or
twice daily, the accumulated pus and secretions
are expressed through the mesh and removed with
an applicator stick. It has been found that “roll-
ing” with an applicator stick prevents the grafts
from lifting up. By the third day, the grafts are
well fixed, and by the fifth day the mesh can be

* Manufactured by the Aeroplast Corporation, 420 Dellrose
Avenue, Dayton 3, Ohio.

Figure 3. Fixation of grafts by nylon lace-mesh. Immobiliia
tion is by plaster. The take was 100 per cent.

Figure 2. Method of fixation of postage-stamp grafts on a
varicose ulcer. The take was 100 per cent.

safely removed. The technic is best adapted to
postage-stamp grafts, but can be used for small
sheets as well.

RESULTS

Sixteen grafts on nine patients have been han-
dled by this lace-mesh method. Of those patients,
six had thermal burns and two had varicose ulcers
(Figure 2). The take in each case exceeded 90 per
cent. In two of those patients previous grafting by
other methods had failed, and when redressed the
wounds demonstrated continuous profuse drain-
age in spite of vigorous local therapy. In no in-
stance was an allergic reaction to nylon manifest
in this series.

CASE HISTORIES

Case No. 1 (J. F.) was a 75-year-old male who
had sustained thermal burns to the right patella,
pretibial area, and left knee. The areas were de-
brided and treated with soaks, with subsequent
formation of healthy granulation tissue. The right
patella remained partially necrotic however, and
exudate continued to escape from around it. After
suitable granulations had developed, split-thick-
ness postage-stamp grafts were applied to an area
adjacent to the margins of the necrotic bone. The
take after five days was 90 per cent.

Journal of Iowa Medical Society

January, 1962

Figure 4. Postage-stamp grafts applied after a failure of
primary grafting. The photograph is of the patient's right
flank on the first postoperative day. The take was 100 per
cent.

Case No. 2 (R. F. J.) was a 70-year-old man who
had sustained third-degree burns to both legs
when a stove caught his clothing on fire. The burn
was so extensive as to require above-the-knee
amputation on the left. After suitable granula-
tions had formed, the stump was grafted. By fold-
ing the mesh and cutting “V’s” from each corner,
we formed the mesh to the contour of the stump.
On the third postoperative day, the patient rubbed
off part of the grafts from the underside of the
leg. We discovered this, and by lifting a corner of
the mesh we were able once more to cover the af-
fected area with storage autografts without dis-
turbing the remainder of the grafts. The take was
90 per cent.

Case No. 3 (K. H.) was a 7 V2 -month-old girl
who had sustained burns of her right arm when
she pulled a vaporizer upon herself. The involved
area was grafted and immobilized by the pressure
method. Unfortunately, the immobilization was in-
adequate and all of the grafts were lost. In a sub-
sequent attempt, plaster and lace-mesh were ap-
plied in the manner shown in Figure 3. The take
was 100 per cent.

Case No. 4 (L. B.) was an 83-year-old debilitated
woman. She developed a large basal cell carcino-
ma with satellite nodules on her right flank. This
area was excised, and split-thickness grafting was
done. The patient had prominent iliac crests, and
immobilization was difficult. The take was only 70
per cent. Regrafting was done with fixation as
shown in Figure 4, and the take was 100 per cent.

SUMMARY

Fixation of skin grafts by nylon lace-mesh has
been described. This method permits removal of
secretions and at the same time provides adequate
fixation of the graft to its bed. The mesh is cheap
and widely available.

REFERENCES

]. Shea, P. C., Reid, W. A., and Wilkinson, A. H.: Use of
rayon mesh in skin grafting and granulating wounds. Surg.
Gynec. & Obst., 103:241-243, (Aug.) 1956.

2. Freeman, B. S.: Immobilization of skin grafts by wide-
mesh net. Plast. & Reconstr. Surg., 27:194-200, (Feb.) 1961.

SIOUX VALLEY MEDICAL ASSOCIATION
Sioux City, Iowa

WEDNESDAY, FEBRUARY 14, 1962
7 : 00 P.M. Hospitality Room — Sheraton Martin Hotel
THURSDAY, FEBRUARY 15, 1962
Morning Session
St. Joseph Mercy Hospital

8:30 registration — St. Joseph Mercy Hospital

9:00-10:15 panel — laboratory procedures: indications

AND SIGNIFICANCE

Henry Caes, M.D., Pathologist, St. Joseph
Mercy Hospital

Paul F. Smith, Ph.D., South Dakota Medi-
cal School

Edwin H. Shaw, Jr., Ph.D., South Dakota
Medical School

10:30-11:00 “Interpretation of EKG With Training Aid”
— R. C. Larimer, M.D.

11:00-11:20 “Arterial Injury and Repair: Case Report”
A. Kelly, M.D.

11:20-11:40 “Skin Hazard in Farmers” — H. Leiter, M.D.
11:40-12:00 “Electroencephalography: Indications and
Significance” — G. Rausch, M.D.

Afternoon Session
Sheraton Martin Hotel
1:30-2:00 movie — “Complicated Appendicitis”
2:00-2:30 “Athletic Injuries” — Donald Lannin, M.D.,
Director of Shrine Hospital, Minneapolis
2:30-3:00 “Urgent Surgery of New Born” — Bernard
Spencer, M.D., Surgery of Infants and
Children, Minneapolis

3: 15-3: 45 “Knee Injuries in Athletics” — Donald
Lannin, M.D.

3:45-4:15 “Elective Surgery of New Born”— Bernard
Spencer, M.D.

5:30 SOCIAL HOUR AND DINNER

7 : 00 dinner — Ballroom

Banquet Speaker: Honorable Jack
E. Miller, United States Senator

FRIDAY, FEBRUARY 16, 1962
Morning Session

Sheraton Martin Hotel

9:00

9:30

10:00

11:00-12:00

12:00

1:30-2:00

2:00-2:45

3:00-3:30

3:30-4:00

movie — (1) “Next Step”

(2) “Cancer Detection: Proctoscopy
in Office Practice”

“Bleeding in the First Weeks of Life” —
Robert Carter, M.D., Associate Professor
of Pediatrics, S.U.I.

“Use of New Progestational Drugs in Ob
and Gyn” — Clifford Goplerud, M.D., As-
sociate Professor, Ob and Gyn, S.U.I.
“Cancer Chemotherapy” — Fred Ansfield,
M.D., Cancer Research Center, Univer-
sity of Wisconsin
luncheon — Sheraton Martin Hotel
movie — “External Cardiac Resuscitation”
“Control and Management of Nasal Hemor-
rhage”— O. E. Halbert, M.D., Mayo Clinic
“Jaundice in Neonatal Period” — -Robert
Carter, M.D.

“Surgical Treatment of Incompetent Cervi-
cal Os” — Clifford Goplerud, M.D.

Visual Responses to

Cortical Stimulation in the Blind

JOHN BUTTON, M.D., Des Moines, and
TRACY PUTNAM, M.D., Los Angeles

In the last half-century electrical stimulation
studies of the human brain under local anesthesia
have become relatively common. As a result, it is
now well known that stimulation of Broadmann’s
Area 17 produces the sensation of crude visual
phenomena projected to the contralateral side.
Stimulation of adjoining areas may elicit more
complicated visual images. The subject has been
reviewed by Lazarte2- 19> 21 and by Penfield and
Jasper.23’ 26

The idea that electrical stimulation of the oc-
cipital cortex might be employed as a substitute
for normal vision in the blind is not new. It has
been discussed for at least three decades. In 1955,
Shaw27 took out a patent on a device to aid the
blind through direct stimulation of the visual
cortex. He proposed to employ a conventional os-
cillator modulated by a photocell, with leads at-
tached directly to electrodes implanted in the
cortex and brought out through the scalp, as
Heath28 and others had done for different pur-
poses. He also proposed using the output of the
oscillator to supply a large solenoid surrounding
the scalp outside of the occipital lobe. We doubt
that such a device would be successful as de-
scribed, and Shaw apparently never carried out
any actual experiments.

Technics for stimulating intracranial structures
at will over long periods of time in animals are
well known to physiologists. Among the more
sophisticated of these are a buried solenoid, as
employed by Light,29 and a tuned radio receiver,
as demonstrated by Fender.30 Actual use of the
former principle in two human subjects has been
reported by Djourno,18 who was able to restore
a sort of crude hearing by that means.

These possibilities have been familiar to neurolo-
gists for many years. There are, however, certain
equally well recognized objections to their prac-
tical utlization in the treatment of blindness. The
first of these is evidence that long-standing optic

Dr. Button is a graduate of the University of Vienna and
an interne at Iowa Lutheran Hospital. Dr. Putnam was for-
merly the director of the Neurological Institute in New York
City and a professor of neurology at Harvard, and he is now
chief of neurosurgery at Cedars of Lebanon Hospital.

atrophy is followed by an atrophy of the central
visual system (pointed out by von Gudden,
Henschen and others), so that the occipital cortex
of a blind person may not be so receptive of arti-
ficial stimuli as is that of a normal individual. The
second is that normal vision is carried out by
means of an enormous number of nerve cells and
fibers composing a mosaic in the retina, tract,
geniculate body and calcarine cortex.32 It is hardly
conceivable that an artificial device could furnish
as many channels, and difficult to imagine that
it could provide enough channels to create even a
crude spatial image.

A further practical difficulty is that of obtain-
ing a blind volunteer for the pioneering experi-
ments. We were fortunate, however, in obtaining
three such volunteers, and consequently were able
to show that the first of the above objections is
invalid, at least in some cases. Our investigations
were undertaken before we learned of Shaw’s
proposal.

CASE NO. I

Miss Betty C., age 36, had suffered a somewhat
obscure illness at the age of 18 years. The diag-
nosis of a tuberculoma of the occipital region was
made, and a decompressive operation was carried
out over the left occipital bone, leaving a defect.
Unfortunately, the medical records of that illness
have been lost. It is clear, however, that she re-
covered from the acute illness and has remained
in good general health, but with a complete bi-
lateral optic atrophy. This has been reported by
several physicians who have examined her, in-
cluding some at the Mayo Clinic. The optic discs
are flat, chalk-white and completely incapable of
visual perception. The patient has lived the se-
cluded life of a completely blind individual. She
has learned to read Braille and to take care of her
personal needs, but does not go out alone and
has never sought employment.

When the possibility was explained to her that
she might temporarily receive crude impressions
of light as the result of a simple operation and
electrical stimulation, she agreed to the experi-
ment and proved most cooperative.

After some discussion we decided to utilize this
opportunity in the simplest and safest possible
manner, and to leave elaboration to the future.
Accordingly, on October 29, 1957, the patient was
brought to the operating room under light seda-

Journal of Iowa Medical Society

January, 1962

tion, and the occipital area was shaved. She was
then placed face downward on the operating table
with a cerebellar headrest, and under local anes-
thesia four small burr-holes were made just lateral
to the external occipital protuberance, on either
side. Through each, an 18-gauge spinal needle was
inserted to varying depths. Next, a 26-gauge
stainless steel insulated wire with 1 mm. of the
tip scraped bare was inserted through each needle,
and the needle withdrawn over it. Thus, wires
were left 1 cm. lateral to each side of the occipital
protuberance at its upper rim, inserted to depths
of 3 cm. and 5 cm., respectively, and a second set
of wires 1 cm lateral to the protuberance at its
lower rim were left inserted to depths of 1.5 cm.
and 7 cm., respectively. Of these, the wires situ-
ated at depths of 3 and 5 cm. gave the most satis-
factory results.

An attempt was made to lead off electroenceph-
alograms from the electrodes, but this phase of
the experiment had to be abandoned for technical
reasons.

Next, a stimulating current was applied to
various pairs of the electrodes. The patient re-
ported the sensation of flashes of light as soon as
a current of 20 volts at a frequency of 8 pulses
per second was applied. The optimum stimulus
with the apparatus that we used appeared to be
25 volts, 75 pulses per second and approximately
620 microamperes, transmitted as a square wave.
A higher voltage produced moderate local dis-
comfort, and a high rate (up to 100 pulses per
second) produced no change in the sensation. The
d.c. impedance between the electrodes was meas-
ured at 20,000 ohms.

The wires were left in place, and a sterile dress-
ing sealed with collodion was applied. Antibiotics
were administered. Meanwhile, a crude light-
controlled stimulator was assembled. This pro-
vided a somewhat distorted unidirectional square
wave that could be transmitted to the buried
electrodes through a cadmium sulfide photoelectric
cell connected in series. In the dark, only a few
microvolts were transmitted. In a bright light, the
maximum current received by the patient meas-
ured 15-25 volts, 620 microamperes, at a rate of
120 pulses per second, with a pulse duration of .1
milliseconds.

When this device was attached to the buried
wires, it was at once clear that the patient could
tell whether the photocell was illuminated bright-
ly, dimly or not at all. With a few moments’ prac-
tice, she learned to point the photocell at the light
in the room. This she did repeatedly, pointing di-
rectly at a 40-watt bulb regardless of where, un-
known to her, it had been moved. She described
the sensation as a sort of diffuse illumination ap-
pearing across her entire visual field, somewhat
as the sun might appear to a sighted person
through closed eyelids. Following these tests, the
electrodes were removed.

Three months later, wires were reinserted in
approximately the same locations through new

drill holes. On that occasion, four 40-gauge stain-
less steel Formvar-covered wires were used, the
upper two inserted to a depth of 4 cm., and the
lower to a depth of 1.5 cm. They were inserted
through 22-gauge spinal needles, which were then
withdrawn.

The special vibrator stimulator was applied to
the wires in various paired combinations, and
current was applied as before. Light perception
which the patient described as “dazzling,” but not
in the least uncomfortable, was obtained through
the upper wires. Moderate light perception was
obtained through the lower wires, the patient re-
porting that it produced a “tingling in the back of
my head.” We realized that the lower wires had
been implanted too close to the dura (at too shal-
low a depth) for complete comfort, and terminated
the operation because of fatigue on the part of
the patient. The implants were sutured to the
scalp, and the exit wounds were sealed with col-
lodion. Antibiotics were given as before. The wires
were well tolerated over the days that they were
left in place. Two days later, the following ex-
periments were performed.

Experiment No. 1. Two cadmium sulfide photo-
electric cells were attached in series with the out-
put voltage of the vibrator-supply, which in turn
was connected to the upper and lower wires. Hold-
ing the cells in her hand, the patient readily
pointed at lighted lamps containing bulbs of 40-
to 120-watt intensities in her vicinity, perceived
evidence of objects lying in reflected light, pointed
out the locations of windows through perception
of daylight, and perceived the light from the
small candles on her birthday cake. With the
vibrator-supply placed in a shoulder-bag, she was
able to negotiate an illuminated obstacle course
without error. It consisted of lighted lamps spaced
at intervals throughout a large room. Motion pic-
tures were obtained of that performance. The cur-
rent received by the patient during all of the above
tests measured:

20 volts

620 microamperes
120 cycles per second

0.1 milliseconds pulse duration

20,000 ohms d.c. impedance between implants.

Experiment No. 2. The implants were connected
to a square-wave generator capable of operating
at varying frequencies, whereas the original vi-
brator had operated at a fixed frequency of 120
cycles per second. Steady, diffuse light was per-
ceived by the patient at from 50 to 100 cycles per
second. When the frequency was reduced to 20
cycles per second, the patient perceived rhythmic
flickering.

Experiment No. 3. The implants were attached
through the square-wave generator to an elec-
tronic photocell. Light was beamed at the photo-
cell through an old-type television scanning disc.
A small photo film negative containing a pattern
of lines was pasted over the photocell, and an at-
tempt was made to scan the pattern. Flickering

Vol. LII, No. 1

Journal of Iowa Medical Society

shadows were perceived by the patient, but only
when the disc was turned slowly by hand.

Experiment No. 4. When the original vibrator-
supply and cells were attached to the upper and
lower wires at each occipital pole, respectively,
light was reported by the patient over the contra-
lateral eye.

Experiment No. 5. The patient reported that
she received a “different” type of light impression
when, unknown to her, the square waves were
converted into sine waves and back again.

Experiment No. 6. The original vibrator and a
second square-wave generator were attached, re-
spectively, to each of two pairs of cadmium sulfide
photoelectric cells, and thence to the four im-
plants in successive combinations of polarity. In
all tests, the patient reported perceiving varying
patterns of light which she described generally as
“bright balls of light against a background of
dimmer light.” This effect was consistently
achieved when the two pairs of photoelectric cells
were held simultaneously at different distances
from the source of the illumination.

CASE NO. 2

Miss Agnes S., age 32, had suffered a severe
head injury as a result of a fall at age 5. When
she recovered consciousness she was blind, and
a complete optic atrophy developed. At present,
she has no light perception whatever, and no
memory of ever having experienced vision. She
was given special training in childhood and
adolescence, and became expert in reading and
writing Braille. She graduated with honors from
college, and secured employment as a teacher.

This young lady learned of our initial experiments,
and volunteered for tests on herself.

Under local anesthesia and light sedation, four
drill holes were made approximately as in Case
No. 1. As before, 40-gauge stainless steel insulated
wires were inserted through the holes by means
of 20-gauge spinal needles. The same stimulator
was applied. In the operating room, the results
were disappointing, for the patient experienced
only pain from the stimulation.

The wires were sealed in place with collodion
dressing, and the patient returned to her home.
Antibiotics were administered. More elaborate
experiments were then carried out, using the
same photocell-modulated equipment, at various
intervals up to eight weeks. The discomfort re-
sulting from stimulation gradually decreased as
healing proceeded, and gradually the patient be-
gan to undergo an unfamiliar visual experience.
She described it by saying, “I seem to see some
kinds of waves and shimmerings. . . . They’re hard
to describe. Whatever it is that I’m seeing, it’s
definitely something besides the nothing that I’m
used to.” On another occasion she remarked,
“That must be the sun!” The vividness of the ex-
perience seemed to grow with practice, but as a
whole it was never so clear or satisfactory as in
the first case, and it cannot be used for guidance
until improvement is manifested in future experi-
ments. The wires were left in place and perfectly
tolerated for 10 weeks. Then they were removed
without discomfort or inconvenience.

CASE NO. 3

Charles C., age 48, a Negro, had lost the sight
of his left eye 32 years ago, and of his right eye

Figure I. External apparatus used in preliminary attempts to enable blind patients to "see." Two cadmium sulfide photo-
electric cells were attached in series with the output voltage of a vibrator supply, which in turn was connected to wires
implanted at varying depths lateral to the patient's external occipital protuberance.

Journal of Iowa Medical Society

January, 1962

eight years ago. The cause had probably been
glaucoma, though an exact history could not be ob-
tained. Examination of his eyes prior to the present
experiment revealed fixed, distorted pupils and
degenerative opacities in both anterior chambers,
making a study of the eye grounds impossible.
There was no light perception whatever in the
left eye. In the right eye there was minimal light
perception when a strong flashlight was held di-
rectly against the pupil.

The patient was a trained electrical repairman
for the Goodwill Industries in his town. He was
extremely likeable and cooperative, and under-
stood thoroughly the nature of the experiment.
He had volunteered, he said, “to help the doctors
invent a way for all blind people to see.”

Under local anesthesia and light sedation as
before, four drill holes were made approximately
as in the other cases. Stainless steel wires .003
inches in diameter, stranded together in groups of
six, were inserted through 20-gauge needles into
three of the burr holes. An unexplained obstruc-
tion met the drill in the fourth hols, and that hole
was abandoned. The inserted ends of the wires
were staggered so that as much contact as possible
could be made with the cortical cells, and the
insulation at each tip had been scraped off as be-
fore. The total number of wires within the visual
cortex was 18, at depths ranging from 3 to 6 cm.
When the original stimulator was applied, the pa-
tient obtained excellent light perception through
all implants. The current specifications measured
the same as in the two previous cases.

Experiments: The patient was subjected to all
of the experiments described above in the discus-
sion of Case No. 1, and his performance accuracy
was 100 per cent. In addition, he was able to fol-
low the beam of a small flashlight carried by an
attendant approximately 15 feet in advance of
him.

When the generator and photocells were at-
tached to just two wires within a single group, the
patient reported narrowed fields of light percep-
t'on over the contralateral eye. This was a highly
desirable finding, for it was felt that it marked a
step toward eventual image and outline perception.

According to the patient, there was no differ-
ence between the degrees of light perception over
the two eyes, despite the fact that one eye had
been blind for 32 years and the other for only
eight.

When two sets of photocells and two generators
were attached to two groups of wires, the patient
reported seeing patterns of light in two colors — -
red and white.

The wires were removed after three weeks to
rest the patient during the construction of new
equipment.

NEUROPHYSIOLOGICAL STUDIES

Square-wave and sine-wave currents of the
specifications used in the above experiments were
appffed to the visual cortical cells of the five fresh

cadaver brains for periods up to one hour con-
tinuously, and to the visual cortical cells of two
living rhesus monkeys. Subsequent microscopic
examination revealed no evidence of damage to
the cells. These studies, however, are still in
progress, and will continue until the safety of the
above-described procedures in living subjects has
been ascertained.

DISCUSSION

It is clear from these experiments that the visual
cortex remains viable and capable of receiving
stimulation interpretable as visual experience for
many years after the destruction of the optic
nerves. Interpretation of the visual experience,
however, is difficult when there is no memory of
sight.

Obviously, implanting wire electrodes haphaz-
ardly in the region of the visual cortex, and bring-
ing them out through the scalp, must be regarded
as a crude and unsatisfactory procedure. The use
of flat electrodes with multi-point contacts laid
on the surface of Area 17 probably would be
more effective. Doubtless some more refined
method of transmission through the scalp, such as
that employed by Djourno, would be more satis-
factory, and we are at present designing such a
device and also a more nearly adequate oscillator.
We are aware, furthermore, that our current re-
quirement is excessive. Human vision requires
only a hundred-millionth of a volt (Lipetz and
others). With more efficient apparatus and a con-
sequent marked lowering of the voltage require-
ment, no discomfort whatever should be experi-
enced by the patient. More importantly, there
would be considerably less danger of over-stimu-
lation, with its possibly damaging effect on tissue.
At any rate, our experiences and the data we
have acquired have led us to formulate, at least
roughly, the rather rigid requirements of the
total system. They are too complicated, however,
and still too theoretical for further consideration
here.

SUMMARY

In three cases of bilateral optic atrophy, wire
electi'odes were implanted in the visual cortex of
the occipital lobe. Application of an adequate
stimulating current to those electrodes produced
visual experiences in all three patients. With the
aid of a special oscillator controlled by photocells,
two of the patients readily learned to recognize
the relative brightnesses of various objects and to
guide themselves about a lighted room. When
added equipment was attached, two of the pa-
tients reported perceptions of patterns of light,
and one of them reported color perception (red
and white).

Preliminary experiments in which identical cur-
rents were applied to the visual cortex in each
of several living rhesus monkey brains and in
cadaver brains, for periods far in excess of those
during which the living human subjects were sub-

Vol. LII, No. 1

Journal of Iowa Medical Society

jected to them, revealed no evidence of cell dam-
age.

REFERENCES

1. Bickford, R. G., Petersen, M. C„ Dodge, H. W., Jr., and
Sem-Jacobsen, C. W. : Symposium on intracerebral electrog-
raphy; observations on depth stimulation of human brain
through implanted electrographic leads. Proc. Staff Meet.,
Mayo Clin., 28:181-187, (Mar. 25) 1953.

2. Lazarte, J. A.: Personal communications, 1956, 1957, 1958.

3. Dodge, H. W., Jr., Bickford, R. G., Bailey, A. A., Hol-
man, C. B., Petersen, M. C., and Sem-Jacobsen, C. W.: Tech-
nics and potentialities of intracranial electrography. Postgrad.
Med. 15:291-300, (Apr.) 1954.

4. Sem-Jacobsen, C. W., and Petersen, M. C.: Method for
examining electrodes and after-discharges during electrical
stimulation. Electroencephalog. & Clin. Neurophysiol., 8:145-
146, (Feb.) 1956.

5. Gerard, R. W., Marshall, W. H., and Saul, L. J.: Elec-
trical activity of cat’s brain. Arch. Neurol. & Psychiat.,
36:675-738, (Oct.) 1936.

6. Kliiver, H., and Bucy, P. C.: Psychic blindness and
other symptoms following bilateral temporal lobectomy in
rhesus monkeys. Am. J. Physiol., (Abst.), 119:352-353,
(June 1) 1937.

7. Lashley, K. S.: Mechanism of vision; cerebral areas
necessary for pattern vision in rat. J. Comp. Neurol.,
53:419-478, (Dec.) 1931.

8. Poliak, S.: Projection of retina upon cerebral cortex
based upon experiments in monkeys. A. Res. Nerv. & Ment.
Dis., 13:535, 1934.

9. Putnam, T. J., and Putnam, I. K. : Studies on central
visual system: anatomic projection of retinal quadrants on
striate cortex of rabbit. Arch. Neurol. & Psychiat., 16:1-20,
(July) 1926.

10. von Bonin, G., Garol, H. W., and McCulloch, W. S.:
Functional organization of occipital lobe. Biol. Symposia,
7:165-192, 1942.

11. Weinberger, L. M., and Grant, F. C.: Visual hallucina-
tions and their neuro-optical correlates. Arch. Ophth.,
23:166-199, (Jan.) 1940.

12. Dodge, H. W., Jr., and others: Symposium on intra-
cerebral electrography: technic of depth electrography.

Proc. Staff Meet., Mayo Clin., 28:147-155, (Mar. 25) 1953.

13. Tassicker, Graham: Personal communications, 1957-

1958.

14. Van der Kloot, William G.: Personal communications,
1957.

15. Ormerod, F. C.: Personal communications, 1957.

16. McNall, J. W.: Personal communications, 1957.

17. Djourno, Andre: Personal communications, 1957-1958.

18. Djourno, A., and Eyries, C.: Prosthese auditive par
excitation electrique a distance du nerf sensoriel a 1’aide
d’un bobinage inclus a demeure. Presse med., 65:1417,
(Aug. 31) 1957.

19. Sem-Jacobsen, C. W., Petersen, M. C., Dodge, H. W.,
Jr., Lazarte, J. A., and Holman, C. B.: Electroencephalo-
graphic rhythms from depths of parietal, occipital and
temporal lobes in man. Electroencephalog. & Clin. Neuro-
physiol., 8:263-278, (May) 1956.

20. Djourno, A.: La methode des induits et ses applica-
tions. Presse med., 65:1353-1354, (Aug. 3) 1957.

21. Sem-Jacobsen, C. W., Petersen, M. C., Lazarte, J. A.,
Dodge, H. W., Jr. and Holman, C. B.: Intracerebral electro-
graphic recordings from psychotic patients during hallucina-
tions and agitation; preliminary report. Am. J. Psychiat.,
112:278-288, (Oct.) 1955.

22. Merry, John: Personal communication, 1958.

23. Penfield, Wilder, and Jasper, Herbert: Epilepsy and
the Functional Anatomy of the Human Brain. Boston,
Little, Brown and Company, 1954, pp. 54-68.

24. Gastaut, H.: Enrigistrement sous-cortical de l’activite
electrique spontanee et provoquee du lobe occipital humain.
Electroencephalog. & Clin. Neurophysiol., 1:205-221, (May)
1949.

25. Delgado, J. M. R.: Some Functions of the Brain

Studied in Waking Animals; With Possible Diagnostic and
Therapeutic Applications to Human Patients. New Haven,
Yale University School of Medicine, 10 pp.

26. Penfield, Wilder, and Rasmussen, Theodore: The

Cerebral Cortex of Man : A Clinical Study of Localization
of Function. New York, The Macmillan Company, 1950,
248 pp.

27. Shaw, D.: Method and Means for Aiding the Blind.
U. S. Patent No. 2,721,316. Oct. 18, 1955.

28. Hodes, R., Heath, R. G., Founds, W. L., Llewellyn, R.,
and Hendley, C. D.: Implantation of cortical electrodes in
man by stereotaxic method. Am. J. Physiol., (Abst.),
171:735-737, (Dec.) 1952.

29. Light, R. U., and Chaffee, E. L.: Electrical excitation
of nervous system — introducing new principle: remote con-
trol; preliminary report. Science, 79:299-300, (Mar. 30) 1934.

30. Fender, F. A.: Epileptiform convulsions from “remote”
excitation. Arch. Neurol. & Psychiat., 38:259-267, (Aug.)
1937.

31. Djourno, A., Kayser, D., and Guyon, L. : Sur la tolerance
parle neuf d’appareils electriques d’excitation inclus a
demeure. C. Rend. Soc. Biol., 149:1882-1883, (Nov.) 1955.

32. Putnam, T. J. and Liebman, S.: Cortical representa-
tion of macula lutea with special references to theory of
bilateral representation. Arch. Ophth., 28:415-443, (Sept.)
1942.

Figure 2. Holding photoelectric cells in front of him, the blind patient follows the technician around the room. He could
"see" the flashlight beam, and another patient with the same equipment could even locate windows through which daylight
was coming from outside.

State University of Iowa
College of Medicine

Clinical Pathologic Conference

SUMMARY OF CLINICAL FINDINGS

A 19-year-old man was admitted to the University
Hospitals with a sudden onset of blindness and
gradual deterioration into a poorly responsive
state.

At five years of age he had been operated upon
for the correction of a tetralogy of Fallot by anas-
tomosis of the right subclavian and pulmonary
arteries. The results had been extremely good, for
he was able, in subsequent years, to attend school
and to do heavy farm work. There was no history
of cardiac failure.

On the morning of the day prior to his admis-
sion, he had apparently been in excellent health.
The week before, he had had a “cold” without
fever, and two months earlier, he had had some
teeth filled but none extracted. He had been shov-
elling corn, on the afternoon before his admission,
when he experienced sudden loss of vision. His
fellow workers said that he then staggered around
and “turned blue all over.” He was able to walk
with some help, and was taken to the local hos-
pital. Oxygen therapy was started, and his color
improved. He was then able to talk and to dis-
tinguish light from dark. His physician said that
he was not in shock and was not dyspneic. An hour
after his arrival at that local hospital, however,
he became less responsive, thrashed wildly and
vomited several times. During the night, he was
completely unresponsive, and his extremities be-
came fixed in extension. His pulse remained reg-
ular. That night, he became febrile. A lumbar
puncture was done, and 84 cells (type not re-
ported) were found. On the next day, he was
transferred to University Hospitals.

On his arrival here, he had an upper respira-
tory obstruction from vomitus and secretions, and
a nasotracheal tube was put in place. His tempera-
ture was 108°F. (rectal), and it was reduced by
means of ice water enemas and cold packs. His
pulse was 110/min. and regular. His blood pres-
sure was 110/? mm. Hg, and he was responsive
only to very painful stimuli. His extremities were
in extension. His pupils were dilated and fixed,
and there was a bilateral Babinski response. The
optic discs appeared normal. The neck was not

stiff. The left heart border was at the anterior
axillary line. The right ventricle was overaccessi-
ble. There was a continuous thrill in the supraster-
nal notch. On auscultation, a to-and-fro murmur
was heai'd over the manubrium. Low along the
left sternal border at the fifth intercostal space
was a very loud, snapping first sound and a grade
2 systolic murmur which was less loud in the
fourth intercostal space. The lung fields were nor-
mal on auscultation. The liver and spleen were
not palpable. There was no edema, no petechiae
and no enlarged lymph nodes. The right brachial
pulse was strong, but the radial pulse was weak
as compared to the left side. He was cyanotic and
had clubbed fingers.

Initial laboratory studies wei’e as follows: Uri-
nalysis— specific gravity 1.014, pH 6, no albumin,
no sugar, no blood, and microscopic examination
clear. Blood examination — hemoglobin 15.8 Gm.,
red blood cell count 5,790,000/cu. mm., white blood
cell count 17,800/cu. mm., hematocrit 55 per cent.
Lumbar puncture — pi’essure 100 mm. H20, red
blood cells 200, white blood cells 1,080 with 98
per cent polymorphonuclear leukocytes, Pandy
reaction 1+, sugar 69 mg./lOO ml., protein 63
mg./lOO ml., blood sugar 77 mg./lOO ml. An elec-
trocardiogram was abnormal, showing right ven-
tricular hypertrophy and an auricular and ventri-
cular rate of 125. A film taken by portable x-ray
showed the lung fields to be clear and the heart
to be of normal shape and size. Two blood cultures
were reported as showing no growth, and one
was reported as showing Staphylococcus epider-
midis. A spinal fluid culture showed no growth
and was negative for fungi.

The patient’s condition changed very little dur-
ing the next week. A tracheotomy was done on
the day after his admission. He was febrile, with
temperature between 102° and 99.4° F. (rectal).
He had intravenous feedings of 4,000 ml. the first
two days, and then of 2,000 ml. per day. His uri-
nary output was not measured, but was said to
be adequate. Antibiotics were given after the first
specimens for culture had been obtained — peni-
cillin, 800,000 units every eight hours, and strep-
tomycin, 1.0 Gm. every 12 hours.

Vol. LII, No. 1

Journal of Iowa Medical Society

A second lumbar puncture was done six days
after the patient’s admission. The pressure was 160
mm. HoO, there were 100 red blood cells but no
white blood cells, the sugar content was 68
mg./lOO ml., and the cultures were negative.

One week after admission, he rather suddenly
developed rapid and labored respirations, and his
pulse rate quickened. It was noted that he had
not put out any urine for the previous six hours.
His blood pressure was 138/56 mm. Hg, and his
neck veins were distended. An electrocardiogram
demonstrated a ventricular rate of 176/min. and
an auricular rate of 333/min. A repeat chest film
showed a considerable emphysema of the right
lower lobe, with some shift of the mediastinal
structures to the left. The patient was given in-
travenous and later intramuscular Lanatosid-C.
A few hours later, it was necessary to maintain
his blood pressure with norepinephrine, but this
measure proved ineffective within a few hours.
The patient died one week following his admission
and about 12 hours after the sudden change in
his pulse and respiratory rates.

SUMMARY OF CLINICAL DISCUSSION

Dr. R. J. Joynt, Neurology: The CPC for today
concerns a boy with a congenital heart defect that
had been operated upon. He got along very well
until he had a cataclysmic episode that eventuated
in his death. First, I shall call upon a student,
Mr. McBride, to discuss the case.

Mr. John W. McBride , junior ward clerk: The
patient being discussed today was operated upon
at the age of five years for tetralogy of Fallot.
The Blalock-Taussig procedure performed at that
time is not a corrective one but gives symptomatic
relief in that it increases the effective pulmonary
blood flow and, therefore, augments the oxygen
saturation and relieves the cyanosis. Clubbing of
the fingers may be decreased, but may remain.
The hemoglobin and hematocrit, or the poly-
cythemia of these patients, may be brought to
normal or to near-normal values, and these indi-
viduals may be able to work satisfactorily, as did
this young man.

We are told that the patient had had some teeth
filled two months before his admission here, and
that he had had a “cold” without fever about one
week before he fell ill. With the heart lesions of
a tetralogy, we have to consider subacute bacterial
endocarditis. The emboli that are commonly noted
with subacute bacterial endocarditis are usually
small and numerous. With these things in mind,
we should like to attempt fitting the symptoms
and signs of this man’s lesions into the picture
characteristic of subacute bacterial endocarditis.

We are told that he had been diagnosed and
operated upon for tetralogy of Fallot. The over-
accessible right ventricle, the grade 2 systolic
murmur heard in the third and fourth interspaces
to the left of the sternum, the cyanosis and clubbed

fingers, the electrocardiographic findings of right
ventricular hypertrophy and the x-ray findings
that showed a heart of normal shape and size —
all of these are usual in patients with tetralogy.
We believe these findings are compatible with,
and not usually changed by, the Blalock-Taussig
procedure. The murmur heard over the manu-
brium is described as having been a “to-and-fro
murmur.” We’re not quite sure what that means,
but we think that it describes merely the con-
tinuous murmur often heard after the Blalock-
Taussig procedure. It can be called a to-and-fro
murmur because the second sound is heard in
the middle of it. The blood pressure reading
“110/? mm. Hg” is also unclear to us, but we
think it means that the diastolic pressure was zero,
or nearly zero, and such a finding is frequently
reported following this particular operation. The
“snapping” first sound at the fifth interspace to
the left of the sternum may have been due to an
increased pressure in the right ventricle or to an
increased volume in the left, with a snapping
closure in the A-V valves.

The non-palpable liver and spleen, normal lung
findings and lack of edema on the patient’s arrival
here were merely indications to us that this pa-
tient was not in cardiac failure, which is often the
cause of death for these individuals.

The only indication for the sudden onset of
blindness that we have to offer — one that would
not result in macular sparing — is bilateral occipi-
tal infarct. We aren’t told what happened to his
sight until later. After oxygen therapy had been
instituted, he was able to distinguish light from
dark. The bilateral occipital infarct is possibly
best explained by bilateral posterior cerebral
artery occlusion, possibly due to emboli or due
to an embolus of the basilar artery. The patient
was not dyspneic or in shock at the time, and we
feel that this would have been compatible.

He became blue, possibly because of anoxia of
the medulla and respiratory center. He became
less responsive subsequently, thrashed wildly,
vomited, and later became febrile, at one time
having a temperature of 108 °F., rec tally. His ex-
tremities became fixed in extension. He had a
heart rate — possibly tachycardia— of 110/min., but
we don’t know what his normal pulse rate had
been earlier. He had 84 cells of an unknown type
in his cerebral spinal fluid. He was responsive
only to painful stimuli. His pupils were dilated
and fixed, and there were bilateral Babinski re-
sponses. We feel that these findings are best ex-
plained by an embolus or by emboli to the circu-
lation of the brain stem — this being the basilar
artery. We also feel that the weak radial pulse
and the strong brachial pulse suggest emboli or
an embolus.

In the laboratory studies done at this hospital,
the urine analysis was normal. As for the blood
analysis, we find that tetralogy patients frequently

Journal of Iowa Medical Society

January, 1962

have a polycythemia, but that after the Blalock-
Taussig procedure the blood picture becomes more
nearly normal. The findings in this case, though,
we think represent just the upper limits of nor-
mal, and also could possibly be due to the vomit-
ing and hemoconcentration. The white blood cell
count, we feel, was high enough to indicate in-
fection, subacute bacterial endocarditis or tissue
damage. We feel that the red blood cells in the
spinal fluid were merely the result of a trau-
matic spinal puncture, since even non-traumatic
punctures can result in 50-150 cells per cu. mm,
in the fluid. It is significant that the patient had
no stiffness of the neck. The white blood cell count
was 1,080, of which 98 per cent were polymorpho-
nuclear leukocytes. We believe that this suggested
tissue damage, rather than bacterial infection on
the basis of the spinal fluid sugar, which was on
the upper limit of normal. The film taken by port-
able x-ray suggests that the earlier clinical impres-
sion of left heart border at the anterior axillary
line was incorrect.

We feel that further blood culture studies should
have been done, in view of the findings of Staph-
ylococcus epidermidis on one culture. We suspect
that the single positive culture was due to a con-
taminant, but we should like to point out that
Staphylococcus can produce a clinical picture in-
distinguishable from that of subacute bacterial
endocarditis.

We are told that the fluid intake was adequate
for maintenance therapy but that the urine output
was not measured. Antibiotic therapy was insti-
tuted in much the same fashion as it is in sub-
acute bacterial endocarditis or, sometimes, in
cerebrovascular accident. The normal spinal fluid
studies one week later may have been a result
either of the antibiotic therapy or of the passage
of time. The x-ray findings on the seventh day
after admission showed right lower lobe emphy-
sema. That may have been due to the aspiration
of secretions or vomitus that the protocol men-
tions as having produced a ball-valve obstruction
in the right lower lobe bronchus. On the seventh
day, the patient developed rapid and labored
breathing, his pulse rate quickened, his neck veins
distended, and atrial flutter was demonstrated on
an electrocardiogram. These findings, we take to
have been evidence of cardiac failure, possibly
renal failure, and also possibly pulmonary in-
farct. We can’t help wondering what effect ade-
quate intake and output measurements might
have had on the treatment and, in turn, on the
course of this patient’s illness.

Our conclusion, then, is that this patient with
tetralogy of Fallot developed a subacute bacterial
endocarditis with multiple emboli involving the
brain stem. Further, we think that death followed
cardiac failure, with possible renal failure and
possible pulmonary infarct.

Dr. Jacqueline A. Noonan, Pediatrics: I’ve

thought I’d spend most of my time in discussing
the neurological complications that can be ex-
pected in congenital heart disease, since this boy
quite definitely had congenital heart disease, which
doesn’t seem to be very much of a problem at the
present time.

There is no need to go over the protocol in
detail once more. He did have a tetralogy of Fallot,
and it was operated upon by a Blalock procedure.
The operation apparently was successful, and he
was able to work well afterward, to go to school
and to do heavy farm tasks. Apparently the result
was good, and it lasted for 14 years. These figures
suggest that our patient was one of the first to
be subjected to the Blalock procedure.

He had been doing fine, as far as we can tell.
He had had a little cold about one week before
his admission here, without fever, and two months
earlier he had had some teeth filled, but none were
extracted. Suddenly, while shovelling com, he
experienced sudden loss of vision, and then stag-
gered about and turned blue all over. I think we
could talk in some detail about the causes of sud-
den blindness, but I’m inclined to think that this
patient’s blindness was just part of an intracranial
catastrophe — that he lost his vision, was confused
and weak, and perhaps even convulsed. Convul-
sion hasn’t been mentioned in the protocol, but
we are told that he staggered around and turned
blue all over. From the protocol we can’t learn
whether someone actually saw him stagger, or
whether it occurred before anyone noticed his
distress. In any event, his turning blue would sug-
gest either that he had had some convulsive sei-
zure, with loss of respiration for a few moments,
or that he actually aspirated some secretions or
vomitus at that point. After this episode of appar-
ent cyanosis, he was able to walk with help and
was taken to the hospital. There, he improved fol-
lowing oxygen therapy to the extent of being able
to talk and to distinguish light.

There was no evidence that his problem was an
acute congestive failure. He was not dyspneic,
he was not in shock, and an hour later he sud-
denly became quite ill again. So this was a sudden
onset of neurologic disturbance that ultimately
resulted in death, and I think we should discuss
briefly what kind of neurologic problems are com-
mon in children or adults with congenital heart
disease.

Actually, neurologic complications of congenital
heart disease are quite frequent. There hasn’t been
very much written as to the exact incidence, but
there have been a number of papers written by
Tyler,1-3 who reviewed the cases at Baltimore. I
think he found a 25 per cent incidence of various
kinds of neurologic problems in a large group of
patients with congenital heart disease. These were
primarily cyanotic children, a great majority of
whom had tetralogy of Fallot.

One of the more common neurologic difficulties

Vol. LII, No. 1

Journal of Iowa Medical Society

is a loss of consciousness or a convulsion. These so-
called hypoxic spells resulting in loss of conscious-
ness and sometimes convulsions occur in tetralogy
of Fallot. Such an occurrence is most unusual in
a young man like this, who at 19 years of age
probably had a fairly normal saturation as a
result of his operative procedure. Most of the loss-
of-consciousness or hypoxic spells occur in infancy,
and certainly in children under the age of three
years. The spells seem related primarily to low
oxygen saturation, and primarily to low oxygen
content. That is, the susceptible patients are those
who have a relative iron deficiency anemia and
who aren’t provided a high enough oxygen con-
tent by the compensatory mechanism of polycythe-
mia. This isn’t true of later complications. Most
of the children who have a loss of consciousness
have saturations below 60 per cent. In fact, none
occur with a saturation above that figure. As the
saturation falls below 40 per cent — to 30 and 20
per cent, as it does in some children — the spells
are quite common. I mention this as a very com-
mon cause of neurologic disturbance in the pa-
tients with tetralogy of Fallot, but I don’t think
we need to consider it seriously as the cause of
this young man’s difficulty.

The next group of conditions could be classed
as cerebral vascular accidents. Again there prob-
ably are three types. One is cerebral thrombosis.
This, again, is primarily a complication of chil-
dren under two years of age, among whom hy-
poxia seems to be a primary cause. It occurs in
children with low saturations and low oxygen
contents. These thromboses are primarily arterial,
although sometimes venous thromboses occur. It
is often difficult to know where the thrombosis is,
for at postmortem the whole brain is often in-
farcted. Interestingly enough, these children sel-
dom die from cerebral thrombosis. Permanent
brain damage with persistent hemiplegia is com-
mon, but some seem to recover without detectable
neurologic defect. Cerebral thrombosis also oc-
curs in the polycythemic patient. As I have said,
this is not a problem, particularly in the infant
group where the polycythemia doesn’t relate par-
ticularly well to the thrombosis. But in young peo-
ple between 15 and 20 years of age, and in older
people having red blood counts above 8,000,000,
the problem of cerebral thrombosis becomes im-
portant. I think we can exclude this boy from
this possibility. His hemoglobin was 15 Gm., which
is a little higher than normal, and his hematocrit
was 55 per cent, but certainly not in the critical
range.

Then we can talk about cerebral hemorrhage.
This is another complication that isn’t primarily
a complication of tetralogy of Fallot, but cerebral
hemorrhages — particularly ruptured aneurysms —
have been recorded with increasing frequency in
children or adults with coarctation of the aorta.
This boy did not have that type of lesion, and

certainly the cerebrospinal fluid findings weren’t
very consistent with a cerebral hemorrhage.

Next we come to emboli. There are a number
of causes for emboli. They may result, certainly,
from bacterial endocarditis, and this possibility
has been discussed in some detail. Other emboli
may occur, particularly with arteriosclerotic
plaques which have been known to occur in pa-
tients with coarctation of the aorta. Again, I think
perhaps we must consider bacterial endocarditis
in this patient as a cause of an embolic phenom-
enon, but I really don’t think that it is the etiology.
I’ll discuss this point in a little more detail later.

Another possibility that we must consider is
a frequent neurologic complication in cyanotic
patients, particularly in ones with tetralogy of
Fallot. That lesion is a brain abscess. It, as you
know, is not a very frequent finding, but about 10
per cent of all brain abscesses do occur in patients
with congenital heart disease, primarily of the
cyanotic type. The over-all incidence is really not
known. It varies in different series from between
one and seven per cent, but the figure becomes
more significant in autopsies of older patients
with cyanotic heart disease.

Now, let’s decide that this patient had a neuro-
logic complication and that he had one of those
that I have discussed. I’d like to say at this point
that I think this patient had a brain abscess, and
I shall go on to explain why I am of that opinion
and why I have ruled out some of the other pos-
sibilities. He had a sudden onset, but that fact
doesn’t help us very much since any of these con-
ditions can appear suddenly. Now, typically a
brain abscess doesn’t suddenly present itself by
causing blindness and loss of consciousness, but
often the initial symptoms of a brain abscess aren’t
recognized. This boy had had a cold without fever
during the previous week. There was no history
of headache, though one would expect it in a
patient with an abscess. Very often, particularly
in cases of brain abscess following heart disease,
a really good history of the precipitating events
isn’t elicited. The patients haven’t had their teeth
pulled, and they haven’t had their tonsils removed.
They just get brain abscesses, and their histories
don’t indicate a good reason.

Most people feel that probably the brain ab-
scess is secondary to infected emboli, for in pa-
tients with right-to-left shunt, the lungs are by-
passed and this very good filtering system for the
body doesn’t clear the transient bacteremia that
may occur from such a simple stress as chewing
on beefsteak. In any event, this boy had a sudden
catastrophe. At the beginning, he began to im-
prove. He was able to talk and to distinguish
light from dark, but very soon thereafter he be-
came less responsive, thrashed about wildly, vom-
ited several times, became unresponsive and de-
veloped decerebrate rigidity. He also became fe-
brile.

blood pressure approaches normal
more readily, more safely.... simply

(hydroflumethiazide, reserpine, protoveratrine A-antihypertensive formulation)

Early, efficient reduction of blood pressure. Only Salutensin combines
the advantages of protoveratrine A (“the most physiologic, hemody-
namic reversal of hypertension”1) with the basic benefits of thiazide-
rauwolfia therapy. The potentiating/additive effects of these agents2'8
provide increased antihypertensive control at dosage levels which
reduce the incidence and severity of unwanted effects.

Salutensin combines Saluron® (hydroflumethiazide), a more effective
‘dry weight’ diuretic which produces up to 60% greater excretion of
sodium than does chlorothiazide9; reserpine, to block excessive pressor
responses and relieve anxiety; and protoveratrine A, which relieves
arteriolar constriction and reduces peripheral resistance through its
action on the blood pressure reflex receptors in the carotid sinus.
Added advantages for long-term or difficult patients. Salutensin will re-
duce blood pressure (both systolic and diastolic) to normal or near-
normal levels, and maintain it there, in the great majority of cases.
Patients on thiazide/rauwolfia therapy often experience further improve-
ment when transferred to Salutensin. Further, therapy with Salutensin is
both economical and convenient.

Each Salutensin tablet contains: 50 mg. Saluron® (hydroflumethiazide), 0.125 mg. reserpine, and
0.2 mg. protoveratrine A. See Official Package Circular for complete information on dosage, side
effects and precautions.

Supplied: Bottles of 60 scored tablets.

References: 1. Fries, E. D.: In Hypertension, ed. by J. H. Moyer, Saunders, Phila., 1959 p. 123.
2. Fries, E. D.: South M. J. 51:1281 (Oct.) 1958. 3. Finnerty, F. A. and Buchholz, J. H.: GP 17:95
(Feb.) 1958. 4. Gill, R. J., et al.: Am. Pract. &. Digest Treat. 11:1007 (Dec.) 1960. 5. Brest, A. N.
and Moyer, J. H.: J. South Carolina M. A. 56:171 (May) 1960. 6. Wilkins R. W.: Postgrad. Med.
26:59 (July) 1959. 7. Gifford, R. W., Jr.: Read at the Hahnemann Symp. on Hypertension, Phila.
Dec. 8 to 13, 1958. 8. Fries, E. D., e^aj .: J. A. M. A. 166:137 (Jan. 11) 1958. 9. Ford, R. V. and
Nickel!, J.: Ant. Med. &. Clin. Ther. 6:461, 1959.

all the antihypertensive benefits of thiazide-
rauwolfia therapy plus the specific,
physiologic vasodilation of protoveratrine A

11 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS BY SERIAL ADDITION OF
THE INGREDIENTS IN SALUTENSIN IN A TEST CASE

(Adapted from Spiotta, E. J.: Report to Department of Clinical Investigation, Bristol Laboratories)

SALUTENSIN

Hg.

190

180

170

160

150

140

130

120

110

100

(thiazide

thiazide protoveratrine A

thiazide protoveratrine A reserpine)

JAN. FEB. MARCH

12 19 27 3 10 17 24 2 9 17 23 30

3Vi WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS USING SALUTENSIN FROM
THE START OF THERAPY IN A “DOUBLE BLIND’’ CROSSOVER STUDY

Mean Blood Pressures-Systolic (S) and Diastolic (D)

mm
Hg.

190
180
170
160
150
140
130
120
110
100
90
80
70
60
50

In this “double blind” crossover study of 45 patients, the mean systolic and diastolic blood pres-
sures were essentially unchanged or rose during placebo administration, and decreased markedly
during the 25 days of Salutensin therapy. (Smith, C. W.: Report to Department of Clinical Investi-
gation, Bristol Laboratories.)

BRISTOL LABORATORIES/Div. of Bristol-Myers Co., Syracuse, N.Y.

Placebo Followed by Salutensin
(22 patients)

Salutensin Followed by Placebo
(23 patients)

Placebo Salutensin

Before After Before After

Salutensin Placebo

Before After Before After

Journal of Iowa Medical Society

January, 1962

We don’t know much about the lumbar punc-
ture performed at the other hospital, but we do
know that when he got here he was extremely
sick, and had high fever. A repeat lumbar punc-
ture here revealed that there were indeed 1,080
white blood cells per cubic millimeter, 98 per cent
of which were polymorphonuclear leukocytes.
Now in the ordinary brain abscess, one may find
a completely normal spinal fluid. However, if a
patient with a brain abscess develops any leak
into the subarachnoid space, or a rupture into
the ventricle itself as may have happened in this
patient, one would expect to find white blood cells
in the spinal fluid. Such a patient, with evidence
of infection, could be expected to have a stiff
neck, and it’s quite possible that this boy had that
symptom, but was sick enough and had enough
neurologic findings so that it might not have been
apparent. In any case, he did have a great many
white cells, mainly polymorphonuclear leuko-
cytes. The Pandy reaction was positive, he did
have an increased protein, and his sugar was nor-
mal. I think these findings indicate that he had
an abscess rather than an acute bacterial infec-
tion. It probably was a chronic lesion, rather
than a particularly infectious one, for many of
these abscesses are actually sterile at the time
they are drained.

The patient had an acute inflammatory response
in his cerebrospinal fluid. The pressure, interest-
ingly enough, was normal. An increased cerebro-
spinal fluid pressure is expected, though not al-
ways present, in brain abscess cases. Actually, in
my experience with brain abscesses, perfectly nor-
mal spinal fluid pressures and even fluids occur,
and it isn’t until a catastrophe like this takes place
that the diagnosis becomes obvious.

The electrocardiogram at the beginning showed
what one would expect in a patient with tetralogy
of Fallot. The patient had right ventricular hyper-
trophy. A chest x-ray showed a heart normal in
size and shape, and this again would be expected
in a tetralogy. It would mean that he had a func-
tioning Blalock anastomosis, and that the left-to-
right shunt wasn’t large enough to cause left-
sided strain. His heart had tolerated this shunt
quite well. He had two negative blood cultures
and one that grew Staphylococcus epidermidis.
This is a common contaminant, and we don’t know
what its presence meant. It was there, but we don’t
know whether it was significant or not. The spinal
fluid culture was negative, as is very common in
brain abscess. Usually we don’t get a positive
spinal fluid culture.

We don’t know what happened to the patient
after he entered the hospital, except that he didn’t
improve. He stayed the same, and then be became
worse and died. I think it would be interesting at
this point to know what was done for him in order
to make the diagnosis. Was the diagnosis made on
a clinical basis, and was nothing more than anti-

biotics given because of his condition? Usually
in brain abscess or in any of the other conditions
we have talked about, an electroencephalogram is
a useful test to perform, since it is usually positive
in brain abscess cases and is quite often helpful
in localizing the lesion. I think a patient as sick
as this boy was, with his decerebrate rigidity,
would have had an abnormal electroencephalo-
gram no matter what was wrong with him, and I
don’t think it would have been useful in localiz-
ing the lesion. I should be interested, however, in
knowing whether an electroencephalogram was
performed. The other test that is helpful in diag-
nosing a brain abscess is a cerebral angiogram,
and if it isn’t helpful we sometimes have to do
ventriculograms. I should be interested in know-
ing whether any of these tests were performed.

The patient was treated with antibiotics, and
appropriately, penicillin and streptomycin were
given. Penicillin is a useful drug in brain abscess
because the great majority of such lesions are
caused by streptococci, but any organism can
cause a brain abscess, and sometimes mixed or-
ganisms do so. The patient’s lumbar puncture
seemed to show improvement after he had been
treated with antibiotics. Then, one week after
admission, he suddenly became worse, developed
rapid, labored respiration, auricular flutter, con-
gestive failure and shock unresponsive to treat-
ment, and died. I expect that this terminal episode
was a result, in a severely brain-damaged patient,
of respiratory distress, on the basis of secretions
or aspiration of vomitus, congestive failure and
brain damage.

What could we have done for this boy? It
seems that by the time he arrived at this hospital
he was very sick, perhaps beyond recall. Ordi-
narily the treatment for brain abscess, as you
know, is antibiotic therapy and then surgical
drainage.

I should like to know whether any of the tests
I have mentioned were performed.

Dr. Joynt: The electroencephalogram was not
performed. Angiography was considered but not
performed. The patient did have chest x-rays.

Dr. Noonan: Dr. Gillies, will you show us the
chest x-rays, please?

Dr. Carl L. Gillies, Radiology: The heart was
normal and the lung fields were clear.

Dr. William B. Bean, Internal Medicine: How
do you account for the heart’s moving over?

Dr. Gillies: A deeper breath probably accounts
for it.

Dr. Noonan: I think the other possible compli-
cation that I’d like to mention in a little more
detail, as the junior student has, is bacterial endo-
carditis. Actually, brain abscess secondary to in-
fected emboli associated with bacterial endocar-
ditis is relatively rare. My reason for choosing
brain abscess over bacterial endocarditis with em-
boli is the fact that this boy had none of the symp-

Vol. LII, No. 1

Journal of Iowa Medical Society

toms that we would ascribe to bacterial endo-
carditis until the onset of his final illness. As you
know, emboli usually occur later in the course
of bacterial endocarditis. I should have expected
him to have a palpable spleen, and I should have
expected some petechiae. Yet all of these things
might not have occurred. I think bacterial endo-
carditis is a possibility, and that it would have to
remain a diagnosis to be considered. However,
taking all in all, I should think the evidence fits
better with a brain abscess which was probably
in a part of the brain where it didn’t cause symp-
toms until it grew large enough to cause the pa-
tient a lot of trouble, probably rupturing into his
ventricular system, with a cerebritis, ventriculitis
and cerebral edema, eventually resulting in his
death.

Dr. E. S. Rahme, N eurology : What do you mean
by “sterile abscess”?

Dr. Noonan: Quite often a brain abscess may
become walled off by the body’s defenses, and by
the time one aspirates it at surgery, the brain ab-
scess may actually be sterile to culture. Part of
the explanation, of course, is that the patient has
also received antibiotics. What I’m saying is that
I think a lot of the trouble is due to reaction, rather
than to an acute fulminating infectious process.
Quite often brain abscesses don’t grow any or-
ganisms, even though there may be a quart of pus
in the brain. In any event, the purulent exudate
must be drained.

Dr. F. J. Tutunji, resident, Internal Medicine:
Where would you localize the abscess?

Dr. Noonan: I’ll leave that to the neurologists.

Dr. Joynt: The clinical diagnosis made by Dr.
M. W. Van Allen, who followed this case, was sub-
acute bacterial endocarditis with a brain stem
embolus. The possibility of a brain abscess was
considered during the patient’s hospitalization. At
one point, Dr. Van Allen felt that possibly angi-
ography might be indicated, but the patient’s con-
dition at that time was so bad that he didn’t go
ahead.

Dr. Jack M. Layton, Pathology: Before I take
up the autopsy findings, I’d like to discuss the
question that was asked about sterile abscesses. As
you know, abscesses don’t have to be caused by
microorganisms. An abscess is a lesion removed
from a body surface and consists of a central
cavity filled with pus surrounded by a zone of
cellulitis. An abscess may have been produced by
turpentine as well as by a staphylococcus.

The chief autopsy findings were limited to the
heart, brain, kidneys and spleen. A congenital
heart lesion such as a tetralogy of Fallot (i.e., with
an overriding aorta, membranous interventricular
septal defect, pulmonary and subpulmonary steno-
sis, and right ventricular hypertrophy) was pres-
ent, as was a patent end-to-side right subclavian
artery to pulmonary artery anastomosis. This
truly can be called a Blalock operation, for it was

done by Dr. Blalock, and it was one of the first op-
erations of that type that he performed. The pul-
monic valve leaflets were largely fused to form a
dome-shaped structure with a 1 mm. hole at the
apex. There was also some infundibular stenosis.
The interventricular septal defect was 3.5 and the
right ventricle was 2.5 cm. thick — that is to say,
greatly thickened. The heart was enlarged and
weighed 500 Gm. On the medial leaflet of the
tricuspid valve, there were polypoid, reddish-
brown, granular and friable vegetations composed
principally of large thrombi containing various
elements of blood, masses of fibrin admixed with
leukocytes and bacteria — gram-positive cocci that
proved to be alpha hemolytic Streptococci when
cultivated. The valve leaflet also disclosed an area
of recent perforation.

Several small infarcts of recent vintage were
found in the spleen, and one was found in the left
kidney. As another embolic complication of the
bacterial endocarditis, a septic infarct and diffuse
vasculitis were found in the region of the cerebral
peduncles. Thrombosis of the basilar and left pos-
terior cerebral arteries, with infarction of the brain
in the distribution of these vessels, accompanied
these findings. The reaction was consistent with
that which is noted between one and two weeks
after infarction. There was an aneurysm at the
bifurcation of the basilar artery that appeared to
be an atherosclerotic aneurysm, rather than a
congenital berry-type aneurysm, and may have
predisposed to the thrombosis which occurred in
this area.

Thus, we have a patient with tetralogy of Fallot
who had been operated upon by Dr. Blalock at
five years of age. He apparently had had good
health for 14 years. Then he developed an infec-
tion that was followed by acute bacterial endo-
carditis and septic embolization, especially to the
basilar and posterior cerebral arteries. This led
to infarction and the central nervous system
symptoms and signs which have been described. I
believe that he later developed perforation of the
valve leaflet, which eventuated in congestive heart
failure, the immediate cause of his death.

Dr. J. M. Opitz, resident, Pediatrics: Were there
infarctions in either the kidney or the spleen?

Dr. Layton: Yes, there were infarcts — several
in the spleen and one in the lower pole of the left
kidney — all of recent type.

Dr. John A. Gius, Surgery: Had the shunt in-
creased in size as the child grew?

Dr. Layton: I can’t tell you in an objective way,
Dr. Gius. I would need to have before and after
measurements. Maybe Dr. Ehrenhaft would ex-
press a view on this matter.

Dr. Ernest O. Theilen, Internal Medicine: Was
it an acute endocarditis rather than a subacute
endocarditis?

Dr. Layton: It was acute, even though the micro-
organism was an alpha hemolytic Streptococcus.

Journal of Iowa Medical Society

January, 1962

Dr. Bean: How large was the hole in the tri-
cuspid valve?

Dr. Layton: About 5 or 6 mm., in behind the
friable vegetation.

Student: Did anybody hear a murmur or a
change in murmur?

Dr. Joynt: It was not noted.

Student: Could you demonstrate bacteria in the
emboli?

Dr. Layton: Yes, and also in the thrombotic ma-
terial in the basilar and posterior cerebral arteries
and in the brain tissue around it. There was ac-
tually quite a diffuse vasculitis in that region.

Dr. Joynt: Dr. Ehrenhaft, would you like to com-
ment on this case?

Dr. Johann L. Ehrenhaft, Surgery: I should like
to tell you of an incident regarding the patient
under discussion. At the time when he was a pa-
tient at University Hospitals, the phone rang in my
office. Dr. Blalock was calling from Baltimore, and
he asked me whether we had this patient in our
hospital, and stated that he had been one of the
early patients who underwent a Blalock shunt
type operation at Baltimore in 1945. I told him I’d
find out. Dr. Blalock told me that in all likelihood,
from the story he had obtained through the pa-
tient’s father, this patient must have a brain ab-
scess. He also stated that some of the patients who
had had Blalock type anastomoses had developed
brain lesions.

The treatment in patients with tetralogy of
Fallot has undergone considerable change. Oc-
casionally we still use shunting procedures of the
Blalock-Taussig type (subclavian to pulmonary
artery anastomosis), or the Potts-Smith type of
operation (pulmonary artery to descending aorta
anastomosis). The so-called Brock transventricular
valvulotomy was in fashion for a while several
years ago, but it has more or less been discon-
tinued for patients with tetralogy of Fallot. At the
present time we have means available to carry out
total correction of this congenital malformation,
and for this reason, unless our hands are forced,
we tend not to carry out temporary, palliative
operative procedures. The morbidity and mor-
tality in patients who have had previous shunt
procedures, particularly a pulmonary artery to
aorta anastomosis, are greatly increased. In some
patients, correction is nearly impossible because
many adhesions form around the previous opera-
tive sites, producing postoperative bleeding at
the time of definitive operations in conjunction
with the pump oxygenator. Our policy at the pres-
ent time is to delay surgery in patients with te-
tralogy of Fallot as long as possible — preferably
until they reach two, three or four years of age —
and then carry out definitive and total correction
of the congenital malformation. However, there
are occasional patients in whom earlier palliative
procedures become necessary because of poor

growth, cerebral complications or respiratory
difficulties.

Dr. Joynt: Dr. Theilen, perhaps you’d like to
say a word about the treatment in this situation.

Dr. Theilen: I think we shall have to accept the
fact that this patient had an acute bacterial en-
docarditis, but I don’t think that we can rule out
the possibility that his difficulties may have begun
approximately two months before his illness be-
came obvious. That is to say, it may have started
at the time when he had some dental work done.
It is not unusual for two or even three months to
elapse between the onset of illness and its final
diagnosis in someone who has a subacute bacterial
endocarditis due to an alpha hemolytic Strepto-
coccus. Such patients may be relatively asympto-
matic during the early part of the disease.

The treatment of subacute bacterial endocardi-
tis due to alpha hemolytic Streptococcus hasn’t
changed appreciably in the last few years. Pen-
icillin is still the drug of choice. The amount of
the drug to be given per day should be estimated
on the basis of the sensitivity of the organism to
it, in so far as is possible. Five or six million units
per day may be quite adequate. On the other
hand, organisms not inhibited by 0.1 unit of pen-
icillin per milliliter of the patient’s serum may
require rather massive doses in the range of 30,-
000,000 units per day, sometimes in conjunction
with streptomycin. A four- to six-weeks course of
treatment is still generally accepted, but as you
know, a few clinicians have advocated intensive
treatment for as few as 10 days. Dr. Morton Ham-
burger4 recently published an article in j.a.m.a. in
which he reported successful treatment of sub-
acute bacterial endocarditis with oral penicillin
and parenteral streptomycin. This form of treat-
ment was suggested only for those patients in
whom the streptococcus is sensitive to 0.1 unit of
penicillin per milliliter of serum, or less. Oral
penicillin for treatment in this way certainly has
some appeal, but I would caution against its use
except in very carefully selected cases. Subacute
bacterial endocarditis can be a hazardous disease
despite the remarkable advances that have been
made in its treatment.

Dr. Ian Maclean Smith, Internal Medicine: It
has been shown that five blood cultures should be
taken to rule out or to diagnose bacterial en-
docarditis.

Dr. Henry E. Hamilton, Internal Medicine: You
have said “five cultures.” Do you mean that the
specimens should be taken five minutes apart, or
how often?

Dr. Smith: They should be taken at least one
hour apart.

Dr. Noonan: It might be worth mentioning here
that in this particular patient the bacterial en-
docarditis was not manifested until he had suffered
a serious neurologic disturbance, and I am con-
fident that all of the penicillin in the world

Vol. LII, No. 1

Journal of Iowa Medical Society

wouldn’t have made any difference in the out-
come. He had already suffered a fatal embolic ac-
cident.

We can argue each time about whether or not
the bacteremia was caused by dental fillings. I
think we should go to great lengths to impress
upon such patients the importance of good dental
hygiene, for even though there may be no history
of a trip to the dentist, it is possible that with bad
teeth and deep caries, bacteremia may have oc-
curred during the process of chewing. Thus, it is
important for these people to maintain good den-
tal hygiene at all times, and dental extractions or
dental manipulations of any other kind should be
covered by antibiotics. I’m sure we don’t know
whether this boy had antibiotic coverage when he
underwent dental treatment, but he should have
had.

Dr. Daniel B. Stone, Internal Medicine: Since
it’s difficult not to chew, do you recommend total
dental extraction for these people?

Dr. Noonan: No, I don’t think that we’d have to
go that far, but I think that the important thing is
for us to begin stressing the importance of good
dental care at an early age. We talk about this
each time we see children in the heart clinic, but
it’s another thing to get the parents and youngsters
to do as we tell them. For some reason, cyanotic
children tend to have unhealthy teeth, and this
fact makes the problem more serious.

Finally, as Dr. Ehrenhaft has mentioned, neu-
rologic lesions become more of a problem as these
patients survive into adult life. The ones who
don’t die from brain abscesses die from bacterial
endocarditis, and the ones who don’t have Blalock
operations but survive may get cerebral throm-
bosis secondary to marked polycythemia. A Bla-
lock operation may give good clinical improve-
ment, but a serious complication occurring years
later may result in death. Open heart surgery al-

lowing a complete surgical correction, we hope,
will prevent such complications.

CLINICAL DIAGNOSES

Subacute bacterial endocarditis, with a brain-
stem embolus.

STUDENTS' DIAGNOSES

Subacute bacterial endocarditis, with multiple
emboli involving the brain stem

Cause of death: Cardiac failure, with possible
renal failure and possible pulmonary infarct.

DISCUSSANT'S DIAGNOSES

Brain abscess, probably rupturing into the ven-
tricular system, with a cerebritis, ventriculitis and
cerebral edema, eventually resulting in death.

ANATOMICAL DIAGNOSES

Tetralogy of Fallot

Patent end-to-side anastomosis of right sub-
clavian to pulmonary artery

Cardiac enlargement

Bacterial endocarditis

Multiple infected emboli in the spleen, kidney
and brain stem

Thrombosis of the basilar and left posterior
cerebral arteries

Terminal event: Perforation of the pulmonary
valves, and congestive heart failure.

REFERENCES

1. Tyler, H. R., and Clark, D. B.: Incidence of neurological
complications in congenital heart disease. AMA Arch.
Neurol. & Psychiat., 77:17-22, (Jan.) 1957.

2. Tyler, H. R., and Clark, D. B.: Cerebrovascular accidents
in patients with congenital heart disease. AMA Arch. Neurol.
& Psychiat., 7 7:483-489, (May) 1957.

3. Tyler, H. R., and Clark, D. B.: Loss of consciousness and
convulsions with congenital heart disease. AMA Arch. Neurol.
& Psychiat., 79:506-510, (May) 1958.

4. Hamburger, M., Kaplan, S., and Walker, W. F.: Subacute
bacterial endocarditis caused by penicillin-sensitive strepto-
cocci: value of oral phenoxymethyl penicillin and intra-
muscular streptomycin. J.A.M.A., 175:554-557, (Feb 18) 1961.

YOU'LL HEAR ABOUT . . .

The Effects of Steroids on Body Physiology

at the

IMS ANNUAL MEETING
May 13-16, 1962

Veterans Memorial Auditorium, Des Moines

Coming Meetings

in State

Jan 9-10 Obstetrics and Gynecology (S.U.I. Department

of Obstetrics and Gynecology, Division of
Maternal and Child Health of the State De-
partment of Health and Iowa Obstetrical and
Gynecological Society). University Hospitals,
Iowa City

Feb. 13-16 Refresher Course for the General Practitioner
(S.U.I. College of Medicine and the Iowa
Chapter of the American Academy of Gen-
eral Practice). University Hospitals, Iowa City

Feb. 15-16 Sioux Valley Meeting (Sioux Valley Medical
Association). Sheraton-Martin Hotel, Sioux
City

Out of State

Jan. 26 Nuclear Medicine, Part I begins. University

of Southern California, Los Angeles
Jan. 26-27 American Society for Surgery of the Hand.
Palmer House, Chicago

Jan. 26-29 Man and Civilization: Control of the Mind, II.

University of California, San Francisco
Jan. 27-Feb. 1 American Academy of Orthopaedic Surgeons.
Palmer House, Chicago

Jan. 29-30 National Research Council, Committee on
Drug Addiction. Memorial Center for Cancer
and Allied Diseases, New York City
Jan. 29-31 Twenty-sixth Annual Session of the Interna-
tional Medical Assembly of Southwest Texas.
Granada Hotel, San Antonio

Jan. 29-Feb. 1 Medical Genetics (American College of Physi-
cians). University of Michigan Medical School,
Ann Arbor

Jan. 2-6

Jan. 5
Jan. 5
Jan. 7-13

Jan. 8
Jan. 12-13

Jan. 13

Jan. 13
Jan. 13-14

Jan. 15-18

Jan. 15-19
Jan. 17-19

Jan. 17-19

Jan. 18-19

Jan. 18-20
Jan. 19
Jan. 19-20

Jan. 19-20
Jan. 20
Jan. 22-24
Jan. 22-24
Jan. 23-25
Jan. 24
Jan. 24-26
Jan. 25-27

Intermediate Electrocardiography for General
Physicians and Specialists. Center for Con-
tinuation Study, University of Minnesota,
Minneapolis

Conference on Proctology. Presbyterian Medi-
cal Center, San Francisco

Lederle Symposium. Admiral Semmes Hotel,
Mobile, Alabama

Eighth Annual General Practice Review (Uni-
versity of Colorado School of Medicine). Uni-
versity of Colorado Medical Center, Denver
Lederle Symposium. Hotel Lowry, St. Paul
Cataract Surgery Symposium. University of
Kansas College of Medicine, Kansas City,
Kansas

Coronary Arteriosclerosis — Detection and
Management. Stanford University, Palo Alto,
California

Skin Problems in Children. Children’s Hos-
pital, University of California, San Francisco
Psychiatry in Medical Practice (University of
Southern California). San Bernardino County
General Hospital

Internal Medicine — Today’s Problems in Diag-
nosis and Management, and Tomorrow’s Pro-
jections (American College of Physicians).
Ochsner Foundation Hospital, New Orleans
Forensic Pathology. Armed Forces Institute of
Pathology, Washington, D. C.

Seminar for Aviation Medical Examiners.
University of Kansas College of Medicine,
Kansas City, Kansas

Tenth Postgraduate Course, Diabetes in Re-
view: Clinical Conference (American Diabetes
Association in cooperation with University of
Michigan Medical School, Wayne State Uni-
versity College of Medicine, Wayne County
Medical Society, and Michigan Diabetes As-
sociation). Statler Hilton, Detroit (17 and 19)
and University of Michigan, Ann Arbor (18)
Obstetrics and Gynecology (University of
Nebraska in cooperation with the Division of
Maternal and Child Health, Nebraska State
Health Department). Conkling Hall Postgradu-
ate Conference Room, Omaha
American Society of Clinical Radiology. Ari-
zona Biltmore Hotel, Phoenix
American Society of Facial Plastic Surgery.
Hotel Elysee, New York City
A Clinic on Human Disability. Morrison Cen-
ter for Rehabilitation, University of Califor-
nia, San Francisco

Nature and Treatment of Allergic Diseases.
University of California, Los Angeles
Conference on Office Diagnosis. Presbyterian
Medical Center, San Francisco
First Inter-American Conference on Congeni-
tal Defects. Statler Hotel, Los Angeles
Clinical Rheumatology. Mayo Clinic, Roches-
ter, Minnesota

Obstetric Problems in Private Practice. Medi-
cal College of Georgia, Augusta
Lederle Symposium. Sheraton-Portland Hotel,
Portland, Oregon

Western Association of Physicians. Golden
Bough Theater, Carmel, California
Otolaryngology for Specialists. Center for
Continuation Study, University of Minnesota,
Minneapolis

Jan. 29-Feb. 1 American College of Surgeons, Sectional
Meeting. Statler-Hilton and The Biltmore, Los
Angeles

Jan. 29-Feb. 3 Vaginal Approach to Pelvic Surgery. Cook
County Graduate School of Medicine, Chicago
Jan. 29-Feb. 3 Treatment of Varicose Veins. Cook County
Graduate School of Medicine, Chicago
Jan. 29-Feb. 3 Proctoscopy and Sigmoidoscopy. Cook County
Graduate School of Medicine, Chicago
Jan. 30-Feb. 1 Underlying Mechanisms of Demyelination
(Brain Research Institute). University of Cal-
ifornia Medical Center, Los Angeles
Feb. 3 Conference on Office Gynecology and Obstet-

rics. Presbyterian Medical Center, San Fran-
cisco

Feb. 3-6
Feb. 5-6
Feb. 5-7
Feb. 5-8

Feb. 7-9
Feb. 7-10

Feb. 8-10

Congress on Medical Education and Licensure.
Palmer House, Chicago

Cardiac Auscultation. University of Kansas,
Kansas City, Kansas

American Academy of Allergy. Denver-Hilton
Hotel, Denver

Applied Epidemiology (St. Louis County
Health Department, Missouri Division of
Health in cooperation with U. S. Department
of Health, Education and Welfare). St. Louis
County Health Department, Clayton (St.
Louis), Missouri

American Academy of Occupational Medicine.
Pittsburgh-Hilton Hotel, Pittsburgh
American College of Radiology Thirty-eighth
Annual Convention. Roosevelt Hotel, New
York City

Symposium on Infertility (New York Univer-
sity Medical Center and the American Soci-
ety for the Study of Sterility). New York City

Feb. 9-10 Dermatology. University of California, San

Francisco

Feb. 12-14 Pediatric Neurology. Center for Continuation
Study, University of Minnesota, Minneapolis
Feb. 12-16 Pathologic Physiology of the Blood Dyscrasias
(American College of Physicians). Washing-
ton University School of Medicine, St. Louis

Feb. 12-16 Medical-Surgical Clinical Symposia: Endo-

crinology, Neurology and Neurosurgery: Neu-
rologic Psychiatry, Medical Problems in Sur-
gical Patients, Pulmonary Disease, Gastroen-
terology. University of Kansas, Kansas City,
Kansas

Feb. 13-15 Cardiac Emergencies. Medical College of

Georgia, Augusta

Feb. 15-17 Special Viewpoints in Pediatrics. University

of California, San Francisco

Feb. 17 Conference on EENT. Presbyterian Medical

Center, San Francisco

Feb. 17-24 North American Clinical Dermatologic Soci-
ety. Royal Hawaiian Hotel, Honolulu

Feb. 17-24 Second Postgraduate Seminar, International

Medical-Legal Society. Princess Kauilani
Hotel, Honolulu

Feb. 19-21 Radiology and Radioactive Isotopes. Univer-
sity of Kansas, Kansas City, Kansas

Feb. 19-23 Symposia on Challenging Medical Problems
(American College of Physicians). Baylor Uni-
versity College of Medicine, Houston

Feb. 19-Mar. 2 Surgical Technique. Cook County Graduate
School of Medicine, Chicago

(Continued on page xxxv)

Vol. LII, No. 1

Journal of Iowa Medical Society

HAPPY NEW YEAR

Happy New Year in 1962! May it bring peace
and tranquility to a troubled woxdd. May it be
filled with joy for you and yours.

You will make the same old resolutions you
have made in past years, and somehow find that
a busy practice interferes with the fulfillment of
many of your goals. But there are two resolutions
that you certainly should fulfill — to spend more
time with your wife and children, and to give
more consideration to your own health. Think
about those objectives and do something about
achieving them. Tempus fugit!

A TIME AND A PLACE

An excerpt from a paper* by William S. Mid-
dleton bears repetition: “Certain physicians are
splendid raconteurs. To these chosen few should
be reserved the privilege of story-telling in med-
ical meetings. The set stories, particularly if off-
color, lend nothing to the dignity of our sessions.
In many instances, they detract immeasurably
from the effectiveness of a scientific paper. A pro-
fessional audience, although superficially amused
by such diversions, would elect other performers
and platforms of entertainment other than the
scientific sessions.”

Dr. Middleton’s words reflect the feelings of
the vast majority of physicians, and bring to mind,

To everything there is a season, and a time to
every purpose under the heaven;

A time to he horn, and a time to die; a time to
plant and a time to pick up that which is
planted;

A time to kill , and a time to heal; a time to
break down, and a time to build up;

A time to weep, and a time to laugh; a time to
mourn, and a time to dance. . . .

* Middleton, W. S.: Unaccustomed as I am . . ., j.a.m.a.,
178:308-311, (Oct. 21) 1961.

INDUCTION OF LABOR

A recent report by Fields,* of the University of
Pennsylvania, discusses the experience with induc-
tion of labor at the University Hospital from Jan-
uary, 1950, through December, 1959, and empha-
sizes the contraindications and the hazards of such
procedures. Elective induction was performed on
3,645 patients, representing 14.4 per cent of 25,327
deliveries. During the same period, 494 pregnan-
cies (1.9 per cent) were terminated by induction
for either medical or obstetrical indications.

Analysis of the results of elective induction dem-
onstrated that the technic was safe and successful,
but certain complications and hazards were en-
countered. Uterine spasm, fetal distress, postpar-
tum hemorrhage, prolapsed cord, premature sepa-
ration of the placenta and delivery of infants
weighing less than 2,500 Gm. constituted the seri-
ous complications of the procedure. Seven fetal
deaths resulted, though only one of them could
be ascribed to the method.

Greater difficulty had been encountered in the
patients in whom obstetric or metabolic reasons
accounted for the induction of labor. The same
complications occurred as in the patients with
elective induction, but in considerably greater
proportions. The fetal mortality consisted of five
intrapartum and seven neonatal deaths, and the
five intrapartum deaths were regarded as prevent-
able. One patient had developed uterine rupture,
which was attributed to faulty technic.

The fetal mortalities from elective induction and
from cesarean section were compared, and it was
concluded that cesarean section is preferable for
local obstetric indications such as placenta previa,
abruptio placenta and fetal distress. Induction and
delivery by the vaginal route appear adequately
to meet the systemic indications for termination,
such as toxemia, Rh sensitivity and postmaturity.

The author emphasized that every aspect of
induction of labor, both elective and indicated, has
certain dangers — selection of the patient, amni-
otomy and oxytocin administration. No patient
who expresses any objection to the elective induc-
tion or manifests any fear of the consequences
should be persuaded to acquiesce. The delivery
of a premature infant results in increased mor-
bidity and a greater chance of mortality. If the
cervix is not ripe for delivery, induction may have
serious consequences. When termination of preg-
nancy is contemplated, the choice between induc-
tion of labor and cesarean section must be
weighed. Many of these patients are not at term,
and a rigid cervix adds to the hazards of induction.
An unwise selection of a candidate for induction
may bring about some unfortunate sequelae such
as fetal and maternal injury. Amniotomy is not
without danger to the mother and infant, and

* Fields, H.: Hazards and contradictions to induction of
labor, surg., gynec. & obst., 113:497-500, (Oct.) 1961.

Journal of Iowa Medical Society

January, 1962

carries with it a risk of infection and of displace-
ment of the presenting part, with resultant mal-
position, prolapsed cord and prolonged labor.

The technic of induction consists of the con-
tinuous intravenous administration of a dilute
solution of oxytocin, followed by amniotomy after
the cervix has dilated enough to make the mem-
branes readily accessible. Each uterus reacts dif-
ferently to oxytocin, and constant care is required
in its administration. The amount of oxytocin in-
fused must be adjusted to the uterine response,
and only a thoroughly experienced person can
judge the reaction. Excessive amounts result in
uterine spasm, and serious consequences to the
mother and the fetus. The use of synthetic oxy-
tocin precludes the danger of anaphylactoid shock.
Prevention of serious consequences is dependent
upon constant, skilled observation.

The major contraindications to induction are
cephalopelvic disproportion and inadequate per-
sonnel and facilities. In elective induction, the
specific objections are fear and reluctance on the
part of the patient, a fetus weighing less than 2,500
Gm., and an unripe cervix. In indicated induction,
the specific contraindications are the need for im-
mediate termination, the presence of fetal distress,
moderate or severe abruptio placenta, and partial
or central placenta previa.

Dr. Fields concludes: “At present, induction of
labor should be practiced only by experienced
obstetricians in institutions with adequate facilities
and personnel. Every precaution must be taken to
avoid the hazards of induction, and of course all
the contraindications should be respected.”

PROPHYLAXIS FOR RHEUMATIC FEVER

Despite the fact that rheumatic fever can be
prevented by adequate penicillin therapy of strep-
tococcal respiratory infections, patients with acute
rheumatic fever continue to be seen. Impressed
by that fact, Czoniczer, Lees and Massell reviewed
the case histories of 105 patients recently admitted
to the House of the Good Shepherd, in Boston,*
to determine the reasons for the continuing oc-
currence of the disease, to ascertain the character-
istic symptoms of streptococcal infections, and to
make some recommendations for improving rheu-
matic-fever prophylaxis.

The 105 patients were selected on the basis of
specific criteria: an unequivocal diagnosis of rheu-
matic fever; no history of previous rheumatic
fever; the presence of a high antistreptolysin-O
titer; an interval of six to 28 days between the
symptoms of streptococcal infection and the onset
of rheumatic fever in those patients in whom an

* Czoniczer, G., Lees, M., and Massell, B, F.: Streptococcal
infection: need for improved recognition and treatment for
prevention of rheumatic fever, new England j. med., 265:951-
952, (Nov.) 1961.

antecedent streptococcal infection could be iden-
tified in the histories.

Reviewing the 105 cases revealed that not a
single one had received adequate penicillin ther-
apy at the time of the antecedent streptococcal in-
fection. It was assumed that lack of proper treat-
ment was an adequate explanation for the devel-
opment of rheumatic fever in these children. Sixty-
nine of the group had not been given therapy at
the time of the streptococcal infection because a
physician had not been called to see the patient.
Among those 69, the symptoms had been severe in
15, mild in 38 and subclinical in 16. The remaining
36 patients had been seen by physicians. In 14
of them an improper diagnosis had been made,
the doctors having decided in most of these in-
stances that the ailment was of viral origin. In
22 patients, penicillin either was not given or was
given in inadequate amounts, despite a correct
diagnosis of streptococcal infection.

As for symptoms and signs, in the 89 children
who had had clinically evident streptococcal in-
fection, 58 had had sore throat and fever, 17 had
had fever without sore throat, 4 had had sore
throat without fever, and 10 had had respiratory
symptoms without sore throat or fever. If fever
had been used as a clue to streptococcal infection,
70 per cent of all 105 patients would have been
suspected, or 84 per cent of those with symptoms.

In consequence of their study, the authors rec-
ommend that whenever a child is ill in any way,
his mother should take his temperature four times
daily. If definite fever is present (a temperature
of 101° F. or more by mouth), a physician should
be consulted. Unless the cause of the fever is obvi-
ous, a throat culture should be taken. If the cul-
ture is found to be strongly positive for beta hemo-
lytic streptococci, it is likely that the illness is
due to a streptococcal infection. To a child with
definite fever and a strongly positive throat cul-
ture, penicillin should be administered in adequate
dosage. An adequate dose consists of a single in-
jection of 1,200,000 units of benzathine penicillin,
or of 400,000 units of oral penicillin administered
three times a day for 10 days.

It is apparent that parents must be carefully
instructed concerning the indications for calling
a doctor about an ill child. Physicians should cul-
ture the throats of children with a febrile illness
for which the precise cause is not apparent. This
is a frequently neglected procedure. It is a simple
matter to procure material from the throat with
an applicator, to place the applicator in a sterile
tube, and to send it to the nearest laboratory for
culture. Just a single injection of procaine peni-
cillin, or the administration of oral penicillin for
two or three days relieves symptoms and gives
a false sense of security. It will not prevent the
development of rheumatic fever or of acute hemor-
rhagic nephritis!

Vol. LII, No. 1

Journal of Iowa Medical Society

ISONIAZID v. THE COMPLICATIONS OF
TUBERCULOSIS

A report has recently been made by Mount and
Ferebee* on a study by the U. S. Public Health
Service which tested the value of isoniazid in the
prevention of meningitis and other complications
in children with primary tuberculosis. The study
was made over a three-year period by a number
of pediatricians throughout this country and in
San Juan, Toronto and Mexico City.

From the start of the study in January, 1955,
to the date of the report, June, 1957, a total of
2,750 children had entered the study group. To
be eligible, the child had to be asymptomatic, and
any youngster requiring treatment of the disease
was excluded. Children under three years of age
were admitted with a reaction of 5 mm. of indu-
ration to the intermediate dose of P.P.D. Children
three years of age or older had to have roentgeno-
logic evidence of primary tuberculosis in addition
to a positive tuberculin test. One half of the group,
selected at random, were given isoniazid, and the
other half were given placebos that were identical
in appearance to the isoniazid pills. The bottles
were identified by number only. Isoniazid was
given in daily doses of 4 to 6 mg. /Kg. of body
weight. An equivalent number of placebos were
given to the controls. Neither the children and
their parents, nor the clinic staff knew which chil-
dren were receiving the isoniazid and which ones
were receiving the inert substance.

When a child entered the test, he received a
physical examination, a chest roentgenogram and
a tuberculin test. Each month during the first year
he returned to the clinic for another supply of
pills and was given a physical examination for
signs of progression of the disease or complica-
tions. Roentgenograms of the chest were carried
out on each child after one, three, six and twelve
months. At the end of a year, he was given a physi-
cal examination and a tuberculin test, and the
medication was discontinued. During the next two
years, each youngster made clinic visits several
times a year, and x-ray studies and tuberculin
tests were repeated yearly. Follow-up plans in-
clude yearly inquiries into the health of each child,
and x-ray examinations are to be carried out at
12, 14 and 16 years of age.

During the three years of observation, 137 chil-
dren were treated for possible tuberculous com-
plications, and in addition to this group, films
from 100 children were judged to show roentgeno-
logic evidence of unfavorable changes during the
first year of observation. From this total of 237
children reviewed by the panel of participating
physicians, 153 were judged to have shown un-
favorable changes definitely or possibly associated

* Mount, F. W., and Ferebee, S. H.: Preventive effect of
isoniazid in treatment of primary tuberculosis in children.
NEW ENGLAND j. med., 2 65:713-721, (Oct. 12) 1961.

with their tuberculosis. In 84 children there were
no unfavorable tuberculous changes. In the iso-
niazid-treated group, 29 children showed increases
in the sizes of the parenchymal lesion, in contrast
with 43 in the group that had received placebos.
One child in each group had a possible cavity in
an area of increased density. In six children in
each group, adverse pulmonary changes occurred
that were regarded as of doubtful tuberculous
origin.

During the first year of the study, the differ-
ence in the development of extrapulmonary com-
plications in the 1,394 children receiving isoniazid
and the 1,356 children receiving placebos was
striking. Only two in the treated group developed
complications. In one child a cervical spine lesion
was recognized four months after he began taking
isoniazid. The second child developed a minimal
pleural effusion with an accompanying parenchy-
mal density after a month of isoniazid. In contrast,
31 children in the group receiving placebos de-
veloped definite complications — six developed
skeletal lesions; nine effusions; three clinical ill-
ness; one tonsillitis; and three conjunctivitis.
Doubtful complications occurred in six additional
children in each of the two groups.

An analysis of the first-year results demon-
strated that the risk of complications is contingent
upon age and upon the extent of the roentgeno-
graphic involvement. Risk increases with the ex-
tent of involvement as demonstrated by roentgeno-
gram, and decreases with age. For all children
less than one year of age, the risk of complications
was high — 16 per 1,000 of those with normal roent-
genograms, and 182 per 1,000 of those with paren-
chymal involvement. For children from one
through six years of age, the risk was substantial
only if x-ray demonstrated parenchymal involve-
ment.

To date, all children have had two years of ob-
servation after the year of treatment. In four
children who had received isoniazid and in eight
who had received placebos, extrapulmonary or
reinfection tuberculosis developed. From this ex-
perience, it was deduced that isoniazid not merely
suppresses complications, leaving the risk of their
emerging after the cessation of medication, but in
fact prevents tuberculous complications.

As a result of this carefully controlled study,
it has been concluded that a high proportion of
children with primary tuberculosis can be induced
to take medication regularly for a year; that
isoniazid in a dosage of 4 to 6 mg./day is safe for
prolonged administration; that the drug appears to
reduce the frequency of adverse pulmonary
changes in children with primary tuberculosis;
and that isoniazid definitely prevents extrapulmo-
nary complications.

Journal of Iowa Medical Society

January, 1962

MORES OF TEENAGERS

In a discussion of teen-age morals in England,
Alex Comfort1 says, “The over-all incidence of
illegitimate births and premaritally-conceived chil-
dren has remained extremely stable since the
1930’s, but the distribution has changed to younger
age groups, in step with the steady secular fall in
the age of physical puberty.” An editorial in the
British medical journal points out that in Norway
and Sweden in 1840, the average girl reached the
menarche at the age of 17 years, whereas at pres-
ent the average girl reaches it at about 13 V2 years.
In Britain a similar pattern has been noted. In-
deed the trend is continuing, for in the last two
London County Council surveys, conducted at
five-year intervals, there has been an average dif-
ference of exactly two months. It was concluded
that the reduction in the age of the menarche has
been continuous at about four months per decade,
or roughly one year per generation. The phenom-
enon has been attributed to improvements in
nutrition and to less serious disease.

Regarding venereal disease in immigrants and
adolescents, another British medical journal edi-
torial3 concludes: “It seems likely that an increase
in venereal disease in adolescents — resulting, pre-
sumably, from greater promiscuity — has contrib-
uted to the larger number of cases coming to the
clinics in recent years.”

In his discussion of teen-age morals, Comfort1
states: “Modern youngsters not only develop ear-
lier; they win prizes or prison sentences, go to
the ballet, take part in political meetings, and
engage in sexual intercourse earlier. The magni-
tude of the shift is such that interests and prob-
lems of the sixth-former today are roughly those
of the undergraduate of yesterday. . . . Some part
of the shift may be socially rather than physiolog-
ically determined, if only to the extent that slower
developers will be carried along faster; the influ-
ence of books, television and other war-horses,
which carry would-be censors to battle, may not
be real. The point of interest is that it is probably
no greater in altering the conduct of the group
than that of their elders. . . . The age of consent
has not advanced with earlier puberty.” The
author points out that there has been no cataclys-
mic change in morals between the present gener-
ation and those immediately before them, and in
so far as there is a teen-age morals problem it is
a reflection of the earlier physical maturity of
young people, and their confrontation with moral
choices at an earlier age. He concludes: “There is
unfortunately only one way of making sure that
the mature bodies of our children contain the emo-
tionally mature minds which are needed for the
painless management of personal relations, not
only sexual ones, and that is by our own example.
... It would be a gain in frankness and honesty
at least, one might think, if in the future the gap

between Sunday pretenses and weekly reality
could be narrowed.”

A contribution by Gallagher4 should be brought
to the attention of all parents with the greatest of
emphasis: “The answer to the question ‘What can
be done about adolescents?’ lies primarily in what
we can do about little children. It is the very early
years which count most. If they are good ones,
the chances that adolescence will go smoothly are
significantly increased. ... If in the first year par-
ents, intuitively or through their doctor’s or oth-
ers’ counseling, see to it that the baby’s needs are
gratified; that in the next two years he can ex-
press warm feelings, develop spontaneity and learn
there are limits; that in the years before he goes
off to school he can experience the feeling of in-
tegrity in his family and from this learn, by good
example, those interpersonal relationships which
are the basis for good sexual adjustment — then
there is less likelihood that in adolescence he will
be resentful, demanding, suspicious, unable to ac-
cept authority, overly anxious about sex or about
becoming an adult, or need to seek recognition in
socially inappropriate ways.”

Parents have a tremendous responsibility to
equip their children for wholesome personal rela-
tionships at adolescence and in the subsequent
years. The average parent is crying for help as
he attempts to do a good job of child-rearing. The
family physician can and should offer valuable
counsel to assure the accomplishment of that goal.
Moralizing with the youngster who is already a
teenager, or attempting to restrain him or her by
instilling fear, is futile. Instead, strength, discip-
line, idealism, character must be woven into the
fabric of the youngster long before the critical
adolescent period.

references

1. Comfort, A.: Teenage morals. Lancet, 1:1335-1336,

(June 17) 1961.

2. Editorial: "Early Maturing and Larger Children.” Brit-
ish M.J., 2:502, (Aug. 19) 1961.

3. Editorial: “Venereal Disease in Immigrants and Adoles-
cents.” British M.J., 2 :224-225, (July 22) 1961.

4. Gallagher, J. R.: Doctor and other factors in adoles-
cents’ health and disease. J. Pediatrics, 59:752-755, (Nov.)
1961.

yOU'LL HEAR ABOUT . . .

Cooperation between medicine and labor
to assure the best possible health care for
the American people

at the

IMS ANNUAL MEETING
May 13-16, 1962

Veterans Memorial Auditorium, Des Moines

Vol. LII, No. 1

Journal of Iowa Medical Society

Presidents Page

Your president-elect, Dr. G. H. Scanlon, and I re-
cently had a very frank talk with Mr. Lawrence Put-
ney, chairman of the State Board of Social Welfare,
for the purpose of exchanging views regarding the
vendor payment programs. The importance of ef-
fective auditing by committees of local physicians
dominated our discussion.

The Iowa Medical Society has always favored local
control of these programs, and to a great extent phy-
sicians can have this local control if they will ex-
ercise it through committees in their respective coun-
ties.

I hope that all county medical societies participat-
ing in the vendor payment programs will determine
at once whether or not their local review committees
are functioning properly, and if not, that they will
take the necessary steps to strengthen them.

President,

BOOKS RECEIVED

PROCEEDINGS OF THE THIRD CONFERENCE ON CAR-
DIOVASCULAR DISEASES, ed. by Robert G. Siekert,
M.D., and Jack P. Whisnant, M.D. (New York City, Grune
& Stratton, Inc., 1961. $5.75).

BIOLOGICAL ACTIVITY OF THE LEUCOCYTE (CIBA
FOUNDATION STUDY GROUP NO. 10), ed. by G. E. W.
Wolstenholme, M.B., and Maeve O’Connor , B.A. (Boston,
Little, Brown and Company, 1961. $2.50).

PROGESTERONE AND THE DEFENSE MECHANISM OF
PREGNANCY (CIBA FOUNDATION STUDY GROUP NO.
9), ed. by G. E. W. Wolstenholme, M.B., and Margaret P.
Cameron, M.A. (Boston, Little, Brown and Company, 1961.
$2.50).

BOOK REVIEWS

Williams Obstetrics, Twelfth Edition, by Nicholson J.
Eastman, M.D., and Louis M. Heilman, M.D. (New
York City, Appleton-Century-Crofts, 1961. $16.00) .

This twelfth edition of what has been for many
American physicians the “bible” of obstetrics is, in-
deed, a monumental work. The two authors have
covered the broad field of obstetrics in all its aspects,
both from the standpoint of the normal and the abnor-
mal, and the end result is a reference book admirably
suited to the needs of the medical student and of the
practicing physician as well.

The first portion of the book is devoted to the anat-
omy and physiology of reproduction, and to the man-
agement of normal pregnancy, as well as to the physi-
ology and conduct of normal labor. Throughout this
portion, however, the authors constantly relate the
theoretical knowledge of this subject to its clinical
application. The chapter on the psychiatric aspects of
childbearing is lucidly done, and any physician han-
dling parturient women would derive much benefit
from it.

The use of the x-ray in pelvic mensuration is dis-
cussed very frankly in the light of possible damage
due to excess radiation, and good, clear-cut indica-
tions are given for its use. This presentation no doubt
will tend to halt the indiscriminate use of the x-ray
that has been prevalent in some quarters during the
past decade or more.

The second portion of the book covers thoroughly
the abnormalities of pregnancy, labor and the puer-
perium, as related both to the mother and to the
newborn. In this portion, the practical side is partic-
ularly stressed, and the busy practitioner will find
this a ready source of answers for many of his per-
plexing clinical problems.

One is particularly impressed with the frankness
with which the authors have discussed postpartum
hemorrhage, particularly as related to uterine atony.
They are very realistic in their approach to this seri-

ous problem, and recommend hysterectomy not as a
last, desperate resort, but as the treatment of choice
when other reasonable measures have failed and be-
fore the patient is in extremis. They wisely point out
that “too little, too late” can be fatal.

The authors have drawn freely upon the works of
other writers, and have given due credit to them. The
bibliography at the end of each chapter is most volu-
minous and complete.

Anyone who deals with pregnancy, be he medical
student, research scientist or clinician, will find this
book most useful. — C. W. Seihert, M.D.

Somatic Stability in the Newly Born, ed. by G. E. W.

Wolstenholme, M.B., and Maeve O’Connor, B.A.

(Boston, Little, Brown and Company, 1961. $10.00).

This volume is a compilation of papers presented at
a symposium on the newly born by an imposing array
of world authorities. The majority of the papers deal
with work in animals, and are profoundly scientific.
However, many of the findings can be translated into
data that are applicable to the human species, and
the papers that deal with human beings are likewise
outstanding.

This isn’t a volume that the average practitioner
would read from the standpoint of finding ways to
improve his clinical care of children. Rather, it is a
book that will appeal to medical men who are espe-
cially interested in basic science and who wish ex-
planations for some of the problems that arise in
the newborn. It is to be used more as a reference book
than as a clinical text. — Charles J. Baker, M.D.

Key and Conwell’s Management of Fractures, Dis-
locations and Sprains, Seventh Edition, by Fred C.

Reynolds, M.D., and H. Earle Conwell, M.D. (St.

Louis, The C. V. Mosby Company, 1961. $27.00).

This is a revision of one of the standard texts in its
field by Dr. Fred C. Reynolds, Dr. Key’s successor at
Washington University School of Medicine.

The book contains two sections, the first being on
principles and general aspects, and the second on the
diagnosis and treatment of specific injuries. The first
portion consists of basic information, well worded,
and kept pertinent so that the reader doesn’t lose
himself in extraneous material. This information should
be prerequisite in any training program, and as a
reference work this book should be used frequently
by many physicians.

The section on diagnosis and treatment is well doc-
umented with many illustrations, and the respective
chapters are limited to certain bones or joint regions.

Vol. LII, No. 1

Journal of Iowa Medical Society

Discussion of these is again good, with the emphasis
placed, as it should be, mainly on conservative meas-
ures. Complications are also dealt with, and the man-
agement of each is outlined.

This book is excellent from the standpoints both of
the student and of the doctor in training and practice.
The material that it contains has been tested and
accepted, and it can serve as a text and as a guide
for the man who wants specific help for a particular
fracture situation.

I am sure that this book will continue to be used
frequently and advantageously by those who become
acquainted with it. — Donald W. Blair, M.D.

Appraisal of Current Concepts in Anesthesiology,

ed. by John Adriani, M.D. (St. Louis, The C. V.

Mosby Company, 1961. $7.75).

According to the editor, this book is designed for
the clinician, as a synthesis of the voluminous mate-
rials that have been written relative to the specialty
of anesthesiology. It is not a “review article,” analyz-
ing the subject and reviewing the literature in minute
detail. Rather, in a few concise pages, the highlights
of the current literature on a given topic are sum-
marized.

The book originated as part of the residency train-
ing program of the Department of Anesthesia at Char-
ity Hospital, New Orleans. Selected topics were as-
signed to residents and staff members at residency
meetings, and the resultant reports were originally
mimeographed for use by the Charity Hospital group.
Then, the papers were edited by Dr. Adriani and
published in book form.

The volume contains 45 chapters, averaging about
five pages each. It is of convenient, coat-pocket size,
and is sturdily bound and attractively printed. Be-
cause it is easy to carry, it can be available for brows-
ing during short “break” periods. The chapters are
brief enough so that one can be read in just a few
minutes.

For its stated purpose — a review of selected topics —
the book can be highly recommended, and it should
be of value for those who are away from academic
centers and for part-time anesthesiologists. — K. Garth
Huston, M.D.

Practical Pediatric Dermatology, Second Edition, by
Morris Leider, M.D. (St. Louis, The C. V. Mosby
Company, 1961. $13.75).

The second edition of this treatise on pediatric
dermatology follows the first edition after a span of
six years. Major changes have been made in the dis-
cussions of the pyodermas and fungus infections. Also,
the uses of new therapeutic agents have been incor-
porated into the discussions of such matters as staph-
ylococcal infections and intractable infections.

The reader searching for bibliographies will be dis-
appointed. The author states in his preface: “The fact
is I found I could write enough out of my head of
what I knew to be true without searching for contem-
poraneous authority greater than my own.”

This book should serve as a useful reference work
for the pediatrician and general practitioner in deal-
ing with the dermatological problems of children. —
M. E. Alberts, M.D.

Mechanisms of Disease: an Introduction to Pathol-
ogy, by Ruy Perez-Tamayo, M.D. (Philadelphia,
W. B. Saunders Company, 1961. $14.00).

This book is a translation and abridged adaptation
of principios de pathologia, which was published in
Spanish in 1959. It is a scholarly yet readable, stimulat-
ing treatise in which a rather successful attempt has
been made to present a survey of some of the basic
mechanisms of disease. The author is professor and
director of the Department of Pathology at the School
of Medicine of the National University of Mexico.

Important topics which are very well reviewed are
disturbances of growth and differentiation of tissues,
the general pathology of connective tissues, host-
parasite relations, disturbances of metabolism and
nutrition, and problems of body fluids and electrolytes.
Discussions of inflammation, of degenerative and re-
gressive disturbances of cells and tissues, and of re-
pair, regeneration and tissue transplantation are sur-
prisingly interesting.

Finally, a good review of the general pathology of
tumors has been included, encompassing discussions
of their etiology, anatomy, physiology and biochemis-
try, their dissemination, and their diagnosis. — R. F.
Birge, M.D.

Clinical Obstetrics, by Benjamin Tenney, M.D., and

Brian Little, M.D. (Philadelphia, W. B. Saunders

Company, 1961. $8.50).

It is pleasant to see a text designed for practical
everyday problems and unencumbered by needless
phrases, clinical obstetrics was written for the pur-
pose of presenting a useful approach and method of
management for use in obstetrical conditions.

Medical complications are discussed from the stand-
point of physiological changes, and the resultant man-
agement is predicated upon those changes. Heart dis-
ease in pregnancy is discussed particularly clearly,
and diabetes management is presented according to
the standards of the Joslin Clinic. The controversial
use of hormones in diabetes may have been given
excess weight. The hypertensive diseases are catego-
rized in the most practical way that I have seen. The
laboratory differentiation between renal disease and
toxemia is particularly valuable.

Blood incompatibilities, premature rupture of the
membranes, prolonged labor, current thoughts on
urinary-tract infection, and many other topics are also
clearly outlined. It is interesting to note that the
authors believe endocrines have no place in the man-
agement of threatened abortion, reasoning that if the
patient is bleeding, damage to the pregnancy has
already been done. There must have been something
wrong to cause the abortion, and therefore endocrines
are of no value. They feel that endocrines should be
reserved for preparation for the next pregnancy, if
they are to be used at all.

clinical obstetrics is not designed as a comprehen-
sive text dealing with background, research findings
and basic science. Rather, it fills the need for a ref-
erence work on the common clinical problems in
obstetrics. The general practitioner should find it indis-
pensable, and the specialist will find that it helps him
review infrequently-seen problems. — Michael R. Hirsch,
M.D.

A refresher course for the general practitioner
will be held at University Hospitals in Iowa City,
February 13-16. Twenty-seven hours of Category
I credit will be allowed for this course sponsored
by the Iowa Chapter of the American Academy
of General Practice and the S.U.I. College of
Medicine.

Registration fees are $40.00 for the complete
course or $15.00 for a single day. Members of the
AAGP will be charged a fee of $10.00. Luncheon
tickets are included in the $40.00 fee; AAGP mem-
bers may purchase them for $1.00 at the registra-
tion desk, where tickets for the Thursday evening
dinner may also be bought.

Advance housing arrangements and parking
permits may be obtained by writing to John A.
Gius, M.D., Director of Postgraduate Medical
Studies, University Hospitals, Iowa City.

This year’s program, the schedule of which fol-
lows, includes motion picture clinics on several
different surgical topics. The clinics will run
simultaneously from 7:30 to 9:30 p.m. on Tuesday,
February 13. Most of the movies shown will be
films that have been produced at S.U.I. , and each
will be personally narrated by the faculty mem-
ber who was involved in the case. Question and
answer periods will follow each film. Programs
listing the subjects to be covered in the film clin-
ics will be distributed at the conference registra-
tion desk, and each physician will be given the
opportunity to indicate his choice.

Narrators of the films will include Dr. L. J. De-
E-acker, assistant professor of anesthesiology; Dr.
J. L. Ehrenhaft, professor of surgery; Dr. M. S.
Lawrence, associate professor of surgery; Dr.
D. M. Lierle, professor and head of otolaryngol-
ogy; Dr. Russell Meyers, professor of neurosur-
gery; and Dr. I. V. Ponseti, professor of ortho-
pedics.

PROGRAM

Tuesday , February 13, 1962

8:15 Registration

8:45 Welcome and Orientation

N. B. Nelson, M.D., Dean, College of Medicine
J. A. Gius, M.D., Director of Postgraduate
Studies

V. L. Schlaser, M.D., President, Iowa Chapter,
American Academy of General Practice

SURGERY

R. T. Tidrick, M.D., Chairman

9:00 Office Treatment of Ocular Injuries

F. C. Blodi, M.D.

9:20 Early Recognition of Congenital Defects of the
Lower Extremities

I. V. Ponseti, M.D.

9: 40 Peripheral Arterial Occulsive Disease: What

Can the Surgeon Offer

Harold Laufman, M.D., Associate Professor of
Surgery and Director of Experimental Sur-
gery, Northwestern University Medical
School

10:40 Temporal Bone Surgery for Deafness: Who Can
Be Helped?

J. A. Donaldson, M.D.

11:00 Question and Answer Period

Harold Laufman, M.D.

F. C. Blodi, M.D.

J. A. Donaldson, M.D.

I. V. Ponseti, M.D.

11:15 Symposium: Bladder Neck Obstruction in Child-
hood

R. H. Flocks, M.D., Moderator

B. J. Begley, M.D.

D. Dunphy, M.D.

C. L. Gillies, M.D.

12: 30 Luncheon — Doctors’ Dining Room

1:30 Short Presentations of Practical Techniques:

Working With Small Structures — J. A. Gius,
M.D.

Mechanical Means for Reducing Chronic
Lymphedema — E. E. Mason, M.D.

The Quick Venous Cut Down — N. P. Rossi,
M.D.

The Difficult Catheterization — D. A. Culp, M.D.

Gastric Hypothermia for Acute Upper G.I.
Bleeding — R. D. Liechty, M.D.

Field Block and Infiltration Anesthesia for
Hernia Repair — J. Kyed Pedersen. M.D.

Examination of the Sperm — R. G. Bunge, M.D.

Emergency Tracheostomy — W. C. Huffman, |
M.D.

3:50 Panel Discussion With Audience Participation:
How Would You Do It?

S. E. Ziffren, M.D., Moderator

Harold Laufman, M.D.

D. M. Sensenig, M.D.

R. C. Hickey, M.D.

5:00 Adjournment

■

Vol. LII, No. 1

Journal of Iowa Medical Society

Evening Meeting
7:30-9:30 Motion picture clinics.

Wednesday, Febriiary 14, 1962
PEDIATRICS

D. Dunphy, M.D., Chairman

Seminar on Neonatal Problems

9:00 Introductory Remarks
D. Dunphy, M.D.

9:15 Neurological Examination of the Neonate

J. C. MacQueen, M.D., and H. Zellweger, M.D.
10: 30 Infection in the Neonate

R. B. Kugel, M.D.

11:00 Choice of Formulas

S. J. Fomon, M.D.

11:30 Surgical Emergencies

R. T. Soper, M.D.

12:00 Question and Answer Period
12:30 Luncheon — Doctors’ Dining Room
1: 30 Small Group Conferences — Therapy in Pediatrics:
Exchange Transfusions in Accidental Poison-
ings— R. E. Carter, M.D.

Croup — Recognition and Management — J. C.
Taylor, M.D.

Endocrine Emergencies in the Neonate — C. H.
Read, M.D.

Immediate Therapy for Convulsions — J. C.
MacQueen, M.D.

C. H. Read, M.D., Chairman

2:30 Steroids, Therapeutic Use and Hazards
R. D. Gauchat, M.D.

3: 00 Common Orthopedic Problems and Their Man-
agement

M. Bonfiglio, M.D.

3:30 Question and Answer Period
4:00 Clinical Pathological Conference

Thursday, February 15, 1962

OBSTETRICS AND GYNECOLOGY

W. C. Keettel, M.D., Chairman

9: 00 Dysfunctional Uterine Bleeding
C. P. Goplerud, M.D.

9: 30 Office Gynecology

W. C. Keettel, M.D.

10:00 Preeclampsia, Management and Prevention

Clyde L. Randall, M.D., Professor and Head of
Obstetrics and Gynecology, University of
Buffalo School of Medicine, Buffalo, New
York

10: 45 Use of Oxytocic Drugs in Obstetrics:

Induction of Labor — W. C. Keettel, M.D.
Uterine Inertia — W. F. Howard, M.D.

Third Stage — J. P. Jacobs, M.D.

11:15 Recent Advances in Obstetrics and Gynecology:
Use of Progesterone as a Pregnancy Test — J. T.
Bradbury, Sc.D.

Treatment of Chronic Trichomonas Infection —
W. C. Keettel, M.D.

Oral Contraceptives — J. P. Jacobs, M.D.

Nasal Syntocin Spray — L. A. Luhman, M.D.

Simplified Postpartum Care — C. P. Goplerud,
M.D.

Vaginal Cytology in Pregnancy — C. A. White,
M.D.

11:45 Question and Answer Period

12:30 Luncheon — Doctors’ Dining Room

1:30 Small Group Conferences:

Menopausal Problems — Clyde L. Randall, M.D.
Rational Use of Hormones — J. T. Bradbury,
Sc.D.

Infertility Problems — J. P. Jacobs, M.D.

Ward Rounds — Obstetrics — W. C. Keettel, M.D.
Manikin Demonstration — Breech — C. P. Gople-
rud, M.D.

Rh Sensitization — C. A. White, M.D.

Abnormal Uterine Activity- — W. F. Howard,
M.D.

C. P. Goplerud, M.D., Chairman

2:30 Diagnosis and Management of Abnormal Pres-
entations

Clyde L. Randall, M.D.

3: 00 Endometriosis:

Symptoms — Clinical Findings — Clyde L. Ran-
dall, M.D.

Hormonal Mangement — C. A. White, M.D.
Surgical Management — C. P. Goplerud, M.D.

4:00 Obstetrical Analgesia and Anesthesia:
Paracervical Block — R. M. Pitkin, M.D.
Pudendal Block — J. P. Jacobs, M.D.

Newer Drugs — W. F. Howard, M.D.

Saddle Block — C. A. White, M.D.

6:00 Social Hour and Dinner — Elks Club, 525 E. Wash-
ington St. (Sophomore and Junior Medical
Students, and the Speaker Will Be Guests of
the Academy)

Speaker: Dr. James P. Cooney, New York
Vice President for Medical Affairs
American Cancer Society, Inc.

“Unproved Cancer Therapy”

Friday, February 16, 1962
MEDICINE

W. M. Kirkendall, M.D., Chairman

9: 00 Clinical Masquerades of Acute Cardiac Infarc-
tion

W. B. Bean, M.D.

9: 20 Diagnosis of Vascular Aging
F. M. Abboud, B.Ch.

9:40 Family Plagues of Boils
I. M. Smith, M.D.

10:10 Management of the Patient With Headaches

Adrian Ostfeld, M.D., Associate Professor of
Preventive Medicine, University of Illinois
College of Medicine, Chicago

10:55 Panel Discussion — Cardiogenic Shock
J W. Eckstein, M.D., Moderator
F. M. Abboud, B.Ch.

E. O. Theilen, M.D

11:55 Nutrition in Rheumatoid Arthritis
R. E. Hodges, M.D.

12:15 Rationale for Employment of Insulin and Hypo-
glycemic Drugs in Diabetes
R. C. Hardin, M.D.

12: 30 Luncheon

Journal of Iowa Medical Society

January, 1962

1:30 Small Group Conferences:

1. The Brittle Diabetic — R. C. Hardin, M.D.,
Chairman; D. B. Stone, D.P.M.; R. E. Cech,
M.D.

2. Problems in Treatment of Patients With Hy-
pertension and Renal Diseases — W. M. Kir-
kendall, M.D., Chairman; H. L. Nash, M.D.;
M. L. Armstrong, M.D.

3. Recent Devolpments in Prevention and Treat-
ment of Coronary Artery Heart Disease —
W. E. Connor, M.D., Chairman; J. C. Hoak,
M.D.

4. Clinical Recognition of Cardiac Valvular
Lesions (Cardioscope Demonstration) — E. O.
Theilen, M.D., Chairman; June M. Fisher,
M.D.; J. W. Evans, M.D.

5. Diagnosis of Anemia — W. M. Fowler, M.D.,
Chairman; Helen Vodopick, M.D.; D. T.
Kaung, M.D.; J. M. McMahon, M.D.

6. Respiratory Tract Diseases — G. N. Bedell,
M.D., Chairman; P. M. Seebohm, M.D.;
I. Horowitz, M.D.

R. D. Eckhardt, M.D., Chairman

2:30 Panel Discussion — Psyche, Soma and the Gut
D. B. Stone, D.P.M., Chairman
J. Clancy, Ch.B.

J. A. Clifton, M.D.

Adrian Ostfeld, M.D.

3: 30 Cervical Spondylosis and Myelopathy
A. L. Sahs, M.D.

4:00 (To be inserted — Dermatology)

R. G. Carney, M.D.

4:20 (To be inserted — Psychiatry)

R. L. Jenkins, M.D.

"REPORT FROM EUROPE"

By Arthur Veysey, chief of Chicago tribune’s
London Bureau*

Britain’s socialized medicine is due for reform
but is unlikely to get it.

Almost all medical bills are sent to the treasury
for payment and so long as that situation prevails,
most Britons will be content with almost any
kind of medical care.

Very few Britons have continued to meet their
own bills since the postwar socialist government
offered to pay. About a million Britons are covered
by hospital insurance policies but the amount in-
volved is only about 15 million dollars a year of
a total national medical bill approaching 3 billion
dollars. (The American figure is about 30 billion
dollars, of which three-fourths is paid by individ-
uals directly or through health insurance.)

In Britain, government medicine is by far the
most popular of all social services. Few persons
want it ended, although many want changes. The
service is popular not because it is good but be-
cause it is “free.”

The most frequent criticisms are that the serv-
ice is too impersonal or that it is insufficient. Pa-
tients object because they wait an hour or two
to see their doctor, or months for hospital treat-

* From the Chicago Sunday tribune — November 19, 1961.

ment that is not considered urgent. The hospitals
have 500,000 patients on their waiting lists.

OBJECT TO ATTITUDES OF MEDICAL STAFF

Once in a hospital, they complain that doctors
and nurses tend to treat them “as if we were no-
body” and that “hospitals seem to be run for the
doctors and nurses instead of the patients.”

Opinions on whether the service is good or bad
tend to vary according to personal experiences.
Nationwide statistics indicate only that health
here has improved at about the same pace as it
has in nations with private medicine.

There are signs that government medicine has
been drawing too heavily on its inheritance from
earlier days and that British medicine may be
falling behind improved world standards.

The medical profession is discontented. Most
older doctors continue to give their best, but a
third of the young doctors are emigrating and
their places in hospitals are being filled by young 1
doctors from India, Pakistan and Ireland.

MANY HOSPITALS OVER 100 YEARS OLD

Hospital facilities are deplorable. Two-thirds of
the nation’s hospitals were built in the last cen-
tury. Many are “temporary” wartime sheds. The
first postwar hospitals are being opened, but
most old buildings will be needed for many years.

Doctors should be the best judge of how well
government medicine works, and a fourth of the
doctors have taken out private hospital insurance
for themselves and their families.

Because almost all hospitals are government
owned and almost all medical men are on govern-
ment payrolls, the rare private or insured patient
almost always goes to the same hospitals and is
looked after by the same staff as the government
patients. However, he can pick the hospital, the
type of room, the time, the surgeon, and the spe-
cialist. He can keep some control over his fate.

When the British patient hears the size of bills
American patients get from their doctors and hos-
pitals, he shuts up, gives thanks for government
medicine and wonders how long it will be until
American patients rebel and, for better or worse,
let someone like the late Aneurin Bevan, who
hated doctors, create a government service.

TOMORROW'S CHALLENGE TO THE
BRITISH HOSPITALS

Susan Cooper

This is Part Two of a London Sunday times in-
quiry, published in that newspaper on November
19, 1961.

The sight of them is familiar enough to most of
us: the dark, Victorian-built hospitals, with their
rows of narrow windows cheerless as barracks.
The problems which they create are not.

The man told by his doctor that he must enter a

Vol. LII, No. 1

Journal of Iowa Medical Society

hospital for a hernia operation is outraged to find
that he must wait eighteen months for a bed. The
woman at an ante-natal clinic, attended by an
Indian doctor and a Jamaican nurse, is startled
to find that half the medical staff of her local hos-
pital comes from the Commonwealth, and that the
National Health Service would collapse tomorrow
if all the overseas doctors in Britain suddenly de-
cided to go home.

Both these problems depend to a large extent on
the abysmal state of most of our hospital buildings.
Since the war the strain on hospitals has become
immense, as precedence for building resources has
been taken by houses, schools, offices. Between
1948 and 1957 the population rose from 48,500,000
to 50 million, but the number of staffed hospital
beds actually fell, from 544,000 to 477,000.

WAITING LISTS

In the teaching hospitals there are, on average,
four people in London and five in the provinces
waiting for every surgical bed. In gynecology,
the average waiting-list is nine per bed. At the
Middlesex Hospital there were in 1959 (the latest
figures available) 16 women waiting for each bed,
in the United Cardiff Hospitals 19, in the United
Cambridge Hospitals 22, and at St. Mary’s Hos-
pitals, Manchester, 26 — the equivalent of a wait
of more than three years.

While the waiting lists grow in some hospitals,
beds are closed in others because of shortage of
staff.

The growing national shortage of nurses, which
the General Nursing Council is trying to combat
by improving pay and conditions, and developing
part-time nursing, is naturally most acute in the
hospitals which are most obsolete. The young
nurse can hardly be blamed for preferring a spa-
cious teaching hospital alive with medical students
to a cramped, age-grimed workhouse full of incon-
tinent old people.

Shortage of doctors is similarly localized. Lon-
don teaching hospitals such as Guy’s or St. Bar-
tholomew’s are never likely to have difficulty in
finding junior medical staff, but in northern region-
al hospitals the need is serious. In Manchester,
between 46 and 48 per cent of “housemen” are
foreign: Indians, Greeks, Spaniards, Africans, Ar-
menians, who come to Britain to work for post-
graduate degrees. In the country as a whole, a
quarter of all housemen and registrars come from
overseas.

The lack of young British doctors in hospitals is
due partly to the unfortunate recommendations
of the Willink Committee, which advised a sub-
stantial cut in the intake of medical students, and
partly to a pattern of pay and promotion which
provides only a very long-term incentive. Its
correction is a complex business; but if the physi-
cal condition of our hospitals were better, the
situation would greatly improve. For one thing,
we might curb the eagerness with which potential
house surgeons and registrars are emigrating, es-
pecially to Canada.

A leading pediatrician sighed and looked out of
the window. “You get angry, but you can’t go on
being angry for years on end. You see something
wrong, and try to have it put right, and they say,
all right, you can have that in 1972 ... so you
try to forget about the conditions, and get on
with the job. Doctors aren’t really indignant types.
They haven’t the time.”

The crystallization of the doctors’ anger came in
1959, in the report on British hospitals made by
Lawrence Abel and Walpole Lewin for the BMA.
The amount spent on hospitals since the war, it
said, had been “pitifully small.” Mere moderniza-
tion was no answer. £ one million spent modern-
izing produced £400,000 in subsequent running
costs, whereas £ one million spent on new build-
ing would produce only £150,000.

The Abel-Lewin report, and later the BMA it-
self, announced firmly that a minimum of £750
million, over 10 years, was needed to replace old
hospitals.

Then, in January, 1961, the minister of health,
Mr. Enoch Powell, announced the ministry’s new
10-year plan to spend an eventual total of £500
million. Although this met only two-thirds of their
demand, the doctors’ wrath subsided.

PLANNING

Not all are yet satisfied: “We have a wholly in-
adequate hospital service,” said one flatly. “What’s
needed in this country is far more than £50
million a year — more like £100 million.” But the
BMA describes its present attitude as “guarded ap-
proval,” and Mr. Langton says that the minister’s
total is “probably as far as you can go with present
resources.”

At the Ministry of Health they are cheerful at
the prospect of an expanding program and a deter-
mined minister. There is, they say, “a forward-
looking atmosphere.” But then comes the cold
water: “The BMA figure of £750 million may be
realistic in relation to the need, but not in relation
to what we can actually spend. The biggest hin-
drance is planning itself — the time it takes. For a
three-year hospital project, you know, you have to
start planning three and a half years in advance.
Our architects and regional board planners are
working under full pressure now, and we need far
more of them.”

Admittedly, with the changing pattern of medi-
cine, it is vital that a new hospital service should
be centrally planned. From the probable shifts in
population, the future needs of each area must be
estimated. Specialized units like radiotherapy and
thoracic departments must be spaced out, to avoid
wasteful duplication. The replacement of old geri-
atric and psychiatric hospitals by smaller units in
general hospitals requires central direction. So
does the closer linking of general practitioners
with hospitals, particularly in maternity and casu-
alty work.

But is the whole mechanism of planning too
cumbersome and slow? If £500 million could be
spent more quickly, the Treasury’s excuse for not

Journal of Iowa Medical Society

January, 1962

providing £750 million over 10 years would dis-
appear.

With all due respect to individual ministry plan-
ners, nothing can muffle urgency more effectively
than the deliberate, cautious grinding of the gov-
ernment machine. Consider this, from a member
of a regional board: “It’s going to be at least seven
years before we see any difference in our build-
ings. We had ministry approval here last December
for a comprehensive development scheme. Now we
have to go through a long series of stages with
the ministry, plans going to and fro before we
can eventually put them out to tender. It takes
three years from the date when the minister
first says go ahead, to the date when the first
brick is laid. I feel there are too many checks.
It isn’t enough, for instance, for the ministry to
approve a major scheme — it has to go to the
Treasury as well. The Treasury, really, is the
nigger in the woodpile.”

YEAR TO YEAR

The administrative medical officer in another
region pointed out gloomily that this has been
the case for a long time. Government money
allowed for replacement work counts as revenue,
and is fairly readily available: but new building
demands capital, which has been allotted on a
strictly year-to-year basis.

“If you spend more than your year’s allocation,
the ministry gets very angry. But if, the next year,
you understand, you can’t use your spare money
to redress the balance, you have to send it back.
This has held things up enormously. Suppose you
have a capital program for 1960 of £10,000 and
you haven’t actually managed to spend all that by
the end of the year because, say, the supply of
pipes and radiators has been held up. You have to
send back the money you haven’t spent, and when
the pipes and radiators arrive you must pay for
them out of your 1961 allowance— money which
you could have been using for the next project on
your list.

“The result is that the most vital work may be
postponed. You know you have to spend all your
money by March 31. If you have a £5,000 scheme
that you know can be finished by then, you will
bring it out of its place low down the list of medi-
cal priorities, rather than lose your £5,000 back to
the Treasury.”

He added that although the system seemed in-
sane he could see why it existed. “It’s largely
British tradition, you know — a terrific respect for
public property and money. The regional hospital
boards can’t be given the same freedom that in-
dustry has. . . .”

Though this kind of control will disappear with
a 10-year program in hand, the ministry — and
hence each scheme costing more than a quarter of
a million, carried out under ministry surveillance
— must still depend on the Treasury from year to
year. Many doctors feel that the system is too com-

plex. “What I’d really like to see,” said one, “would
be a region handed over to someone like Unilever
or I.C.I. and have them told: ‘All right, you run
it.’ The saving and the speed would be incredible.”

“You can’t do anything when you’re working for
a Civil Service,” said another. “Only by the Chi-
nese torture method — you know, drip, drip, drip,
wear them away.” He sounded resigned. “There
are people running the National Health Service
who’ve been transferred from the Gas Board. . .

This contrast drawn between the dynamism of
industry and the careful hesitation of bureaucracy
is a hardy perennial. But for the hospital adminis-
trators, the contrast is particularly bitter. After 15
years of neglect, hospitals have come into the
market for the services of architects and builders
only to find that they still have to take their turn
after houses, factories, schools. “With the best will
in the world, no matter how much money you have
to spend on building, the limiting factor is always,
in one word, bricklayers. Often we’re likely to be
bringing in a large building program at the same
time as three big industrial firms. If I’m the head
man in a firm, I can say to the builders, ‘Right,
any bonuses you like, let’s get this finished by
March 31.’ But hospitals are dependent for every
penny on the Treasury. The builders don’t really
want to build the hospital — the frustrations and
delays involved are far greater than the money
they get. So they put in very high tenders, and
hope you won’t accept.”

In this monstrous situation, where the govern-
ment can justify inadequate expenditure by point-
ing out that more money could not be spent even
if it were made available, there is unlikely to be
any marked improvement in the hospital service
for 10 to 15 years — the least optimistic doctors say
25. It is possible to paint the rosiest of pictures by
looking only at the 200 £250,000 projects under
construction or in planning. But while we wait and
wait for these to be completed and succeeded by
others, two things are happening.

POSTPONED

First, bad conditions are growing worse. More
dirt accumulates on old walls, more rust on old
pipes; the ques lengthen and the waiting lists
grow. The promise of rebuilding, jam tomorrow,
becomes a reason for continued neglect.

A consultant at a Birkenhead children’s hospital
told me how, three years ago, a series of balconies
outside the wards of his hospital became unsafe.
Since these were the only places in an urban hos-
pital where children could lie in the open air, the
medical board recommended that they should be
replaced, using money from an endowed fund.
“The management committee had the money, they
had the plans — and they turned the idea down flat.
Just because, at some indefinite and likely-to-be-
postponed date, a new children’s hospital is to be
built in this area, and this one will become redun-
dant. So for the last three years, and no doubt for

Vol. LII, No. 1

Journal of Iowa Medical Society

several years to come, the children at this hospital
are deprived of fresh air.”

Such decisions are not uncommon. It is true that
in many places regional boards are approving
urgent construction schemes even in hospitals
which are due for demolition, and treating the
expense as a write-off. But they feel that their
scanty architectural resources must be reserved
as far as possible for new building. “We will not
patch and mend in this region any more if we can
help it, not unless the scheme suggested involves
a very modest sum. . . .”

Secondly, although the patient will of necessity
wait for new hospitals, medical progress will not.
Already it is advancing with such speed that any
hospital built today is necessarily obsolescent, and
the key word of all planning is “flexibility.”

NEW PATTERN

The war years brought tremendous advances in
antibiotics, blood transfusions, plastic surgery. The
whole pattern is changing. Diseases like pneu-
monia and tuberculosis, once expected to be fatal,
are now controllable, and occupy far fewer beds;
but as new treatments are found for the degener-
ative diseases of an aging population, the strain on
hospital resources is not lessened, but increased.

More mothers want to have their babies in hos-
pitals; but how long will it be before the intense
competition for maternity beds is eased? The acci-
dent rate has doubled since the war, but will it be
one decade or two before an effective national
accident service can be set up and staffed? And
what will the accident rate be by then?

Bad as our hospitals are at present, the worst
of them are likely to grow worse still before the
general situation can be improved. Medical ad-
vances catch up with new hospitals before they
can leave the drawing-board. At all levels, a spirit
of urgency is notably lacking.

Doctors and regional boards, lulled into quiet
relief by a building program which seems frenzied
in comparison with the last neglected 15 years,
talk trustingly of the £500 million which the gov-
ernment is to spend during the next decade. But
will it be spent?

If a total of £500 million is to be reached by
1971, annual expenditure at the end of the decade
must have reached more than £70 million. But if
our architectural and building resources are
strained to the utmost now, in spending half that
amount, how will such an acceleration be possible?

The welfare state is, in this country, the greatest
social experiment of the century, but it is still the
poor relation of national expenditure. Last year,
when we spent £25 million on hospitals, we spent
£81 million on schools. If it is argued that there
are barriers to spending more money on hospitals,
then money should be spent on removing the bar-
riers. There is, according to one eminent hospital
architect, a large untapped reservoir of architects,
surveyors, engineers and contractors who would

be only too willing to build hospitals if they could
be assured of “a clean job.”

“In Nigeria, one British firm has planned, built
and got the first patient into a 200-bed hospital in
two years — the time that we take here to reach
the sketch-plan stage. If only people would let us
get on with the job without endless delays, we

COuld‘ CONSCIENCE

Hospitals are a social service, and only an urgent
spasm in the social conscience can bring them the
full and rapid reform that they need. And the
social conscience belongs in the end not to the
government but to the ordinary man and woman;
the couple whose life centers comfortably around
their car, television set, refrigerator, washing ma-
chine. They are healthy, and they never give
hospitals a thought. If they read of neglected hos-
pitals in their newspaper today, they will forget it
tomorrow.

It would be better to remember, since they are
the people most closely involved. If their car skids
into a tree, it is they who will have to be taken
to the overworked casualty unit housed in an
air-raid shelter left over from the last war.

And it is they who may find themselves eventu-
ally a part of the picture which will haunt me for
a long time, out of the hospitals of modern Britain:
the silent circles where 30 crumbled wrecks of
old men or women sit gazing blankly out at dirty
roofs through narrow windows, in a long, bleak
room with one dubious-smelling lavatory and a
single bathroom stacked with commodes.

They sit above three flights of stone stairs up
which they were carried, months or years ago,
when they came under the generous protection
of their own welfare state, and down which they
will be carried, months or years hence, when they
die.

FILM EXPOSING COMMUNIST IMPERIALISM

The “myth of Western imperialism” is exploded,
and attention is turned to “the real culprit” in a
new film being released by Pepperdine College,
Los Angeles. Called “Communist Imperialism,”
the half-hour sound movie is the second in a
series of 13 being produced for the college by Sid
O. Fields, of Hollywood, on the general theme
“Crisis for Americans.” The first in the series,
“Communist Accent on Youth,” is now in use by
groups in 48 of the 50 states. The films feature
Harry Von Zell as narrator.

Since Karl Marx, the communist propaganda
theme song throughout the world has been that
nations in which the capitalistic system now pre-
vails will ultimately and inevitably become im-
perialistic and will move out and exploit backward
and undeveloped areas through a process of
colonialism.

For additional information, address Mr. Doyle
T. Swain, Pepperdine College, P. O. Box No. 876,
Los Angeles 44.

examinations

THE DOCTOR'S BUSINESS

More About Corporations,
Associations and Pension Plans

HOWARD D. BAKER

WATERLOO

Although corporations, associations and pen-
sion plans for doctors of medicine have been favor-
ite topics of conversation throughout the past
seven or eight years, and although they have been
promoted, periodically, by some of the less con-
servative financial and tax advisors, nothing of
the sort can yet be recommended to the generality
of physicians.

Informed people believe that today we are no
nearer a final solution of this problem than we
were seven years ago. They contend that the pros-
pective revenue loss to the federal government
is so large as to provide the Treasury Department
with adequate incentive for continuing to oppose
such plans indefinitely.

Let’s take a close look at this type of planning.
First, what are corporations and associations, and
what is their purpose? Individual medical prac-
tices and partnerships are not legal entities, and
thus the physicians who choose either of those
patterns are regarded as self-employed, for tax
purposes. Corporations and associations, on the
other hand, are legal entities and have employees
in their own right, including stockholder-employ-
ees. Associations or corporations, theoretically at
least, can provide medical and disability insurance,
pensions, etc. to their employees more advanta-
geously, in so far as taxes are concerned, than self-
employed individuals can provide such things for
themselves, and they can make Social Security
coverage available to them, too.

The association was first employed years ago
by a group of physicians in Montana who wished
to avail themselves of these alleged benefits. Their
form of organization and their pension plan were
ultimately upheld by the courts. Since then, doz-
ens of associations have been formed, only to
meet with varied attacks and delays from the

Mr. Baker is a partner in Professional Management Mid-
west, and manager of its Retirement Planning Department.
He majored in accounting and business administration at
S.U.I., and was an agent of the U. S. Bureau of Internal
Revenue for 3V2 years before forming his present association
in 1953.

Treasury Department. Today, only a small hand-
ful of such organizations have been fully approved.

The association was a logical form of organiza-
tion, since state laws, until 1960, prohibited pro-
fessional people from practicing as corporations.
In 1961, however, many “enlightened” state legis-
latures lowered the bars by passing “service, pro-
fessional or physician corporation laws.” Simply
stated, these acts permitted the practice of various
professions under corporate organization, provided
that there was no non-professional ownership
or control.

At last, it appeared that the way had been
cleared for professional people to incorporate and
enjoy the same benefits that had always been
available to others. So far, however, this has not
proved true. Further obstacles were encountered,
and the Treasury Department is imposing unfore-
seen delays.

WHAT IS THE FUTURE OF THESE ORGANIZATIONS?

One well-informed source states that the Treas-
ury Department is preparing a new attack. He
says that both types of organization (corporate
and association) will receive Treasury approval,
but then an attack will be leveled at classifying
owners as “employees” for tax purposes. In other
words, the types of organization will be sanctioned,
but they will be prevented from achieving their
objective.

In view of the fact that approval of the pension
plans of many existing associations has been pend-
ing for five or six years, and in view of the diffi-
culties of other sorts that have yet to be resolved,
the future for these new organizations doesn’t
seem very bright.

WHO CAN BENEFIT, AND WHAT ARE THE COSTS?

As is so often the case, the benefits afforded by
these organizations must vary directly with the
wealth of the organizers and with their ability to

Vol. LII, No. 1

Journal of Iowa Medical Society

forego the use of substantial amounts of income
for extended periods of time. The doctor who is
currently in a 30 per cent tax bracket and is spend-
ing all he earns (or possibly more) has little to
gain from such an arrangement, for he certainly
is in no position to forego the use of between 10
and 20 per cent of his annual earnings for 20 or
30 years. Similarly, a group consisting of two
financially mature doctors in high tax brackets
and two young, low-income doctors would find it
difficult to take advantage of this type of plan.

The group that might benefit would be one made
up, exclusively, of physicians with high net in-
comes and high degrees of financial security. Yet,
even such a group might find some non-tax factors
that would outweigh the advantages. How much
of the tax saving will the inclusion of non-owner
employees nullify? What effect will the plan have
on the group’s ability to attract prospective asso-
ciates? Will the building up of a large “nest egg”
encourage members to withdraw in order to get
their hands on their shares of the accumulation?
All of these are important questions that must be
answered.

What is the cost of achieving association or cor-
porate organization? We have been quoted fees
ranging from $800 to $2,500, depending upon the
size of the group, just for investigation and or-
ganization. These amounts do not include the costs
of administration or of possible litigation.

our advice: wait!

In summary, our position on these groups still
remains negative, in all but a few exceptional
cases.

If yours is a group for which this type of plan-
ning is contraindicated by none of the difficulties
that I have listed, then we urge you to seek qual-
ified counsel. Dollars invested in qualified counsel
will return handsome dividends.

Finally, it would be most unwise for you to aim
at becoming the first organization of this type in
your vicinity. Let other people make the mistakes,
and then utilize the experience of those pioneers.

CLINICAL OPHTHALMOLOGY

The annual clinical conference of the Chicago
Ophthalmological Society will be held on Febru-
ary 16 and 17 at the Drake Hotel, in Chicago. The
guest speakers will include Drs. David G. Cogan,
Boston; Arthur Gerard DeVoe, New York City;
John R. Fair, Augusta; Trygve Gundersen, Bos-
ton; John S. McGavic, Bryn Mawr, Pennsylvania;
C. Wilbur Rucker, Rochester, Minnesota; Daniel
Ruge, Chicago; and Mr. R. Ross Russell, Oxford,
England.

The subjects to be discussed are: “Retinal Archi-

tecture and Physiology,” “Personal Experiences
With Herpes Simplex Corneae,” “The Management
of Congenital Cataracts,” “Recent Developments
in the Field of Human Toxoplasmosis,” “Congeni-
tal Toxoplasmosis,” “The Surgery of Corneal Dis-
ease,” “Reactions to Lens Cortex,” “The Role of
the Lens in Glaucoma,” “The Optic Chiasma as a
Source of Mistaken Diagnosis,” “Some Sources of
Diagnostic Errors in Neuro-Ophthalmology,”
“Neurosurgical Diagnostic Tests Which Aid in
the Diagnosis of Visual and Ocular Findings,” and
“Platelet Embolism.”

The registration fee for the entire course, in-
cluding round-table luncheons and dinner, is $45,
and is payable to the registrar, Mrs. Mary E. Ryan,
1150 North Lorel Avenue, Chicago 51.

PATIENTS WANT FREE CHOICE OF PHYSICIAN

In the November 27 issue of his Washington
report on the medical sciences, Mr. Gerald Gross
summarized an interesting special article that had
appeared in the November issue of the monthly
labor review, comparing consumer attitudes to-
ward Kaiser Permanente and Blue Cross-Blue
Shield.

For a master’s thesis at the University of Cali-
fornia, Mr. Burton Wolf man surveyed 100 work-
ers enrolled in a liberal Blue Cross-Blue Shield
plan and 100 in a Kaiser Foundation health plan.
All 200 belonged to the same union. The Kaiser
group was slightly younger, on the average, had
25 per cent more children and included nearly
twice as many heads of non-white families. In
each group, the average family income was $6,400.

Here are some of the author’s findings: Though
their monthly premiums were higher, Kaiser fam-
ilies averaged out-of-pocket expenditures of $255
in 1959 for all health costs, including drugs, com-
pared with $312 for “Blue” families. Excluding
premium payments, the former spent 2.4 per cent
of income for medical and hospital care, and the
“Blues” spent 3.8 per cent. Although Kaiser fam-
ilies got more for their health dollar, three-fourths
of the local union’s membership had chosen Blue
Cross-Blue Shield.

The No. 1 reason given by “Blue” families in
explaining their choice of coverage was free choice
of physician and hospital. The other group, on
this point, stressed lower costs and broader bene-
fits.

“In choosing a health plan,” the author con-
cluded, “many of these workers subordinated cost
considerations to subjective factors associated
with health plan membership, including strong
feelings of social class or status and the expecta-
tion of higher quality care.”

RECRUITING MEDICAL ASSISTANTS

In many communities, medical assistants are
invited to participate in high school or junior col-
lege “Career Day” programs. We should accept
these invitations promptly and enthusiastically,
first because they provide us opportunities for
civic service, and second because they give us
chances to improve our public relations. Here are
some of the points that we should bring out in
speaking to these groups of students.

We can begin by asking a series of questions:

Do you like people?

Do you want variety in your work?

Can you “take hold” and get things done?

Do you have some talent for science?

Can you be trusted with confidential informa-
tion?

If each answer is “Yes,” we can undertake to
answer the following questions:

What sorts of work does the medical assistant
do? The medical assistant works in the office of
a doctor of medicine. First, as an office assistant,
she acts as a secretary, receptionist and book-
keeper, she answers the telephone, greets patients,
handles correspondence, keeps track of patients’
accounts and maintains up-to-date medical records.

Second, as a technical assistant, she prepares
patients for examination or for treatment, takes
temperatures, measures heights and weights, ster-
ilizes instruments, and stands by to assist the
doctor as he examines or treats patients. With spe-
cial training, she may perform certain simple lab-
oratory tests, take x-rays and give other medical
assistance to patients under the doctor’s super-
vision.

Third, as a housekeeper, she keeps the office in
order, the waiting room neat and attractive, the
consulting room tidy and ready for use, and she
makes sure the office and laboratory supplies are
arranged properly, and she reorders them when
stocks run low.

What qualifications must one have to become
a medical assistant? Educational standards are
flexible, but one needs basic office skills, a famili-
arity with medical words and phrases, and some
knowledge of medical office practice and labora-
tory procedures. Some of these, one can acquire
on the job.

The recommended education consists of a
planned curriculum in medical assisting in a busi-
ness school or college. The courses now offered
vary in length from one to four years. They com-
bine secretarial training, including medical dicta-

tion and typing, and pertinent sciences and labo-
ratory technics. If such a course is unavailable,
the girl who aspires to become a medical assistant
will find advanced secretarial training or even a
high school business course helpful. One’s final
training, in any case, is on the job, as one learns
how her employer wants things done.

The Iowa Association of Medical Assistants, in
cooperation with the Iowa Medical Society and
the State University of Iowa, sponsors an In-
Service Training Program for Medical Assistants
each fall on the S.U.I. campus in Iowa City.

What salary and working conditions can a med-
ical assistant expect? Doctors’ offices are pleasant
places to work. The work week usually approx-
imates 40 hours, and earnings reflect the local
salary picture. Medical assistants’ salaries are
about equal to those of business office assistants
with comparable amounts of training.

What other rewards can one look for as a med-
ical assistant? A career as a medical assistant is
challenging. One has the satisfaction of helping
people, rendering a real and necessary service
both to the doctor and to his patients.

One can look forward to considerable job-secu-
rity, for the demand for trained medical assistants
will continue to grow. As people seek more and
better medical care, the practice of medicine be-
comes more specialized, and greater numbers of
trained people are needed in all health services.

How can one secure a job as a medical assistant?
A girl who is trained and ready to work should
check the help-wanted ads in her local newspapers,
inquire at medical and commercial employment
agencies, or apply at physicians’ offices.

Where can one get more information about the
job of the medical assistant? Write to the American
Medical Association, 535 North Dearborn Street,
Chicago 10, for the booklet “Winning Ways With
Patients.”

—Helen G. Hughes

Help your central office to
maintain an accurate mailing
list. Send your change of ad-
dress promptly to the Journal,
529-36th Street, Des Moines 12,
Iowa.

Doctors Should Take Every Opportunity to Explain

The Structure and Activities of the
American Medical Association

Last June, at the close of his term as president
of the American Medical Association, Dr. E. Vin-
cent Askey told the AMA House of Delegates that
medicine needs informed defenders. “It is impor-
tant for each of us,” he declared, “to accept the
responsibility for telling our positive story of pub-
lic service, medical research and legislative inter-
ests as often as is humanly possible. People want
to know. There are no Iron or Bamboo curtains in
medicine or in our Association, and we all must be
active spokesmen!” Dr. Leonard W. Larson, who is
Dr. Askey’s successor as AMA president, has re-
iterated that appeal.

THE AMA IS CONTROLLED AT THE GRASS ROOTS

Let’s use every opportunity to tell our fellow
citizens that the AMA, unlike many other national
organizations, is just as responsive to the wishes
and beliefs of the individuals who compose it as is
our United States government. The AMA — now
approaching 115 years of age — has about 180,000
members (roughly 70 per cent of the 255,000 li-
censed doctors of medicine in America), and each
one of those 180,000 is a member of one of the 1,911
county medical societies, and a member of one of
the 54 state and territorial medical societies. The
AMA House of Delegates, its only policy-making
body, contains one representative physician for
every 1,000 members of each state or territorial
organization, and the doctors in the respective
counties are just as fairly represented in the state
or territorial houses of delegates. Each physician
has an opportunity to speak his mind and to make
his influence felt, and the majority rules. Votes
are almost never unanimous. Doctors are the most
independent of thinkers, and they always say what
they think. The idea that there might be reprisals

for failure to follow a “party line” is ridiculous.

The AMA, like a majority of the doctors who
compose it, is conservative, but the fact is that
it supports more legislative proposals than it op-
poses. During the 86th Congress, AMA representa-
tives testified on just 28 of the 700 medical bills
that were introduced. In six instances they ex-
pressed disapproval, but in 19 instances they en-
dorsed the legislation. On the three others, their
statements were merely informational.

Through the years, the AMA has recommended
hundreds of health laws. Its efforts paved the way
for pure food, drugs and cosmetics laws. It has
advocated the tightening of licensure regulations
for each of the health professions. Currently, it
favors one-time grants for expanding medical
school facilities, implementation of the Kerr-Mills
Act by the various states, and federal loans for
proprietary nursing homes, among other proposals.

THE AMA’s LOBBYING EFFORTS ARE MINOR

The AMA maintains a Washington office, manned
by just 13 employees, chiefly for the purpose of
watching the progress of these hundreds of health
proposals that are introduced at each session of
Congress. The AMA staff in the national capital
provides information to the members of the Senate
and House of Representatives, and to the adminis-
trative branch of the government, and on occasion
may exert an effort to influence legislation on cap-
itol hill. In most instances, however, the Washing-
ton office simply sends word to the Chicago head-
quarters that if the beliefs of a majority of doctors
are to prevail, attempts must be made to change
the minds of certain representatives and senators,
and then individual doctors in the respective legis-
lators’ constituencies are asked to write to those

men or to talk with them as soon as possible. The
AMA devotes just seven-tenths of one -per cent of
its annual budget to legislative activities!

THE AMA SERVES THE PUBLIC CONSTANTLY

Article II of the Constitution of the AMA states
that the objective of the organization is “to pro-
mote the science and art of medicine and the bet-
terment of public health.” Let’s make the most of
every chance to tell people how the Association
has worked to achieve that purpose!

The first of the AMA's specific goals was the im-
provement of medical schools. In 1909, when Abra-
ham Flexner studied and reported on the 165
institutions then granting medical degrees, some
schools were admitting students directly from high
school; others were even taking some with only
elementary -school educations. The medical training
that was provided was sketchy. Many schools were
spending more money for advertising than for
laboratories. On the publication of the Flexner re-
port, many of the “diploma mills” closed their
doors, and many others either improved their
offerings or quit a short time later. Today, the 89
colleges of medicine in the United States graduate
better-trained physicians than do the schools that
are located elsewhere in the world. The AMA con-
tinues its work of this sort, however, by inspecting
and supervising internship and residency (special-
ty) training programs at teaching hospitals, many
of which aren’t connected with colleges of medi-
cine. Internes and specialty-trainees are highly
useful in any hospital, and the staffs there must
constantly be reminded not merely to keep those
men busy but to provide them valuable instruction
as well. Through the Joint Commission on Accredi-
tation of Hospitals, the American Hospital Associa-
tion, the American College of Surgeons, the Ameri-
can College of Physicians and the AMA inspect
and put their stamp of approval upon hospitals of
all sorts and sizes, thus insisting upon high stand-
ards of patient care.

For more than a century, the AMA has worked
at exposing charlatans and at enforcing the laws
that are intended to protect people against them.
The AMA Bureau of Investigation cooperates with
the U. S. Food and Drug Administration, the Post
Office Department and the Federal Trade Com-
mission in that task. The Bureau doesn’t itself
prosecute quacks, but it frequently provides the
evidence necessary to convict them. Just this last
fall, together with the federal agencies just named,
the AMA held a Congress on Medical Quackery, in
Washington, as the start of a public education cam-
paign that it hopes will very nearly finish the task
of putting unscrupulous practitioners out of busi-
ness.

The AMA’s efforts have helped make safe and
effective medicines available to patients every-
where. Most of the new remedies have been de-
veloped by the pharmaceutical manufacturers, by
the government’s laboratories, or by the medical
schools with financial help from either the drug
makers or the government, but the AMA has in-
vested more than a million dollars of its member

physicians’ money in these projects, too. More im-
portantly, perhaps, the AMA evaluates medicines
and apparatus used in treating patients, thus help-
ing physicians to provide only the safest and most
effective therapies to their patients. Under a new
and far-reaching drug information program an-
nounced on June 9, 1961, the service is being ex-
panded. A new book, including authoritative sum-
mary statements on drugs and their usage will be
published annually. In a recent three-year period,
996 new products were introduced in the ethical
(prescription) drug area, plus 311 new forms of
old products. Thus, practicing physicians greatly
need just such help as this.

The AMA distributes pamphlets, maintains a
lending library, translates medical articles and
books from foreign languages, and answers innu-
merable questions individually, for both lay people
and doctors, but its principal means of disseminat-
ing information are its meetings and its journals.
It holds two big meetings each year, in June and in
November and December, at each of which literally
hundreds of lectures are delivered and hundreds
of demonstrations are performed. In addition, the
AMA stages numerous meetings each year on
specific medical problems such as school health,
sports injuries, mental health, industrial medicine,
etc.

THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIA-
TION, a weekly magazine that is foremost in its
field, is distributed to all member physicians, and
besides, each member may have his choice of one
of the 10 monthly magazines that the AMA pub-
lishes for specialists of various sorts. A fortnightly
newspaper for physicians, the ama news, is dis-
tributed to all physicians, whether or not they are
members of the AMA, and a monthly magazine for
lay people, today’s health, is published for sub-
scribers, and a copy of each issue is sent to every
member physician for his patients to read in his
waiting room.

Only a few of the other AMA services to doctors
and, through them, to the public can be enumer-
ated here. The AMA provides leadership in dis-
tinguishing between food fads and food facts, in
getting manufacturers to equip cars with safety
devices such as seat belts and padding, in perfect-
ing voluntary health-insurance plans, in improving
the training of auxiliary health-service personnel,
in evaluating the usefulness of such technics as
hypnosis, and in studying the medical aspects of
space exploration and jet-age aviation.

SUMMARY

In short, the American Medical Association
exists because people in general expect more of
physicians, and because physicians expect more of
themselves, than of anyone else. Just as the indi-
vidual doctor of medicine works constantly for the
best interests of his patients, so the organization
to which 180,000 American doctors belong exists
to serve those doctors’ patients. The AMA does not
dominate ; it serves!

Let’s all of us tell those facts as often and as
completely as we can.

STATE DEPARTMENT OF

COMMISSIONER

HEALTH

MORBIDITY REPORT FOR MONTH OF
NOVEMBER 1961

1961

Disease Nov.

1961

Oct.

I960

Nov.

Most Cases Reported
From These Counties

Diphtheria

Scarlet fever

142

156

150

Johnson, Polk, Wood-

Typhoid fever

bury

Smallpox

Measles

191

117

Cerro Gordo, Linn, Pot-

Whooping cough

tawattamie

Pottawattamie

Brucellosis

1 1

Scott

Chickenpox

153

427

Dubuque, Pottawatla-

Meningococcic

meningitis

mie, Woodbury
Butler

Mumps

301

Dickinson, Story, Wood-

Poliomyelitis

bury

Monona

Infectious

hepatitis

120

Boone, Linn, Polk, Scott,

Rabies in animals

Webster

Greene, Woodbury

Malaria

Psittacosis

Q fever

Tuberculosis

For the state

Syphilis

For the state

Gonorrhea

109

For the state

Histoplasmosis

Polk

Food intoxication

Meningitis (type
unspecified )

1 1

Clay

Diphtheria carrier

Aseptic meningitis

Salmonellosis

Des Moines, Johnson

Tetanus

Pocahontas

Chancroid

Encephalitis (type
unspecified )

H. influenzal
meningitis

Amebiasis

Shigellosis

Influenza

Dickinson

POLIOMYELITIS IMMUNIZATIONS

Though a month or two ago would have been
ideal, there is still time to begin poliomyelitis im-
munizations and complete the series of three in-
oculations, using the regularly accepted intervals
between injections, and establish good protection
before the start of the poliomyelitis season. We
are impressed, however, by the fact that many
people, instead of beginning immunizations with
the Salk vaccine, are delaying, probably in the
hope of obtaining the oral, attenuated vaccine.

Type I oral, attenuated poliomyelitis vaccine
was licensed in August, 1961, and Type II was
licensed in October. Type III vaccine may not be
available for some time, however. Though through-
out the country three years ago almost all iso-
lations of poliomyelitis virus were Type I, during
1961 there was a great increase in Type III. Early
summaries indicate that Type III was found in
about 50 per cent of all viral isolations in paralytic
cases during 1961. With this in mind, even though
oral immunizations for poliomyelitis were given
for Types I and II, one would have to give the
regular series of three injections of Salk vaccine
in addition, if patients were to be properly pro-
tected against Type III. A five-injection program
would be difficult to administer in one year, and
even more difficult to explain to the public.

The Iowa State Department of Health agrees
with other state departments of health and with
the Association of State and Territorial Health
Officers that the time for use of the oral vaccine
on a routine basis has not yet come. Dr. Luther
Terry, surgeon general of USPHS, says, “Immuni-
zation programs with oral polio vaccine are not
considered desirable until it is possible to initiate
programs with all three types of vaccine.” Here
are some representative attitudes of other state
departments of health. The November, 1961, issue
of the Illinois health messenger, a publication of
the department of health of that state, declared,
“The Illinois Department of Public Health does
not recognize the oral vaccine as a substitute for
the ‘killed’ polio vaccine, which provides protec-
tion against all three types of paralytic polio.” Cor-
respondence from the director of health in the
State of Washington says: “The Washington State
Department of Health recommends that live, oral,

Journal of Iowa Medical Society

January, 1962

attenuated poliovirus vaccines not be used for indi-
vidual or mass immunizations at this time.”

The Iowa State Department of Health still rec-
ommends that the basic immunization series for
poliomyelitis be three injections of the Salk polio-
myelitis vaccine, and that the regularly accepted
spacing of the injections be followed. Thus, the
second dose follows the first after an interval of
about one month. The third dose follows the second
at a minimum of five months, but usually seven.
The first booster injection is to follow a year after
completion of the basic series of three injections.
There is still some question as to the frequency
of subsequent boosters. Currently, we are advis-
ing that the second booster be given within one
year to two years following the first booster, with
a shorter interval if poliomyelitis becomes an im-
mediate threat in the area.

The basic series of three injections of Salk
vaccine plus the first booster is known to confer
95 per cent protection against paralytic poliomye-
litis.

CARBON MONOXIDE DEATHS
IOWA, I960

The one- or two-line stories listed below, repre-
senting the 13 deaths from carbon monoxide poi-
soning in Iowa during 1960, vividly depict dangers
posed by this colorless, odorless gas, and the tend-
ency many people have either to forget or to
minimize those dangers.

Although the number of carbon monoxide deaths
throughout the country for 1960 is not yet avail-
able, the USPHS records show that there were
644 of them in 1959. Of those, as in Iowa during
1960, a majority (385) wTere attributed to motor
vehicle exhaust.

The months in which the 13 Iowa deaths oc-
curred show that the danger is definitely greatest
during the cold seasons of the year. All 13 Iowa
deaths took place between October 10 and April 22.

Every person we question admits he knows one
shouldn’t run the motor of a car in a garage with
the doors closed. However, many people don’t
realize in how short a time an individual can be
overcome by carbon monoxide. Generally, they
know that gases from a defective exhaust line may
find their way up into a car. Perhaps they don’t
so thoroughly understand that slow-burning fires
(such as a pail of glowing charcoal in the closed
van of a truck) give off large quantities of carbon
monoxide. Perhaps too, many people believe that
if carbon monoxide is present, even in small quan-
tities, they will be able to smell it.

Since the presence of carbon monoxide cannot
be detected by smell, and since its overpowering
action requires so short a time, it is best to take
no chances with it. A little foresight and planning
can enable people to avoid such fatal or near-fatal
accidents.

Death Month of

No. Age Sex Death

1 18 Male January

2 42 Male January

These men were burning charcoal in a bucket in a truck
to prevent perishable materials from freezing. They re-
mained inside the truck.

Male

January

Information

incomplete.

Male

February

Accidental.

This man was

working on a

car with the

motor running. The garage was small and the doors
were closed.

5 17 Female February

Accidental. The car was parked in a garage with the
motor running and the doors closed.

6 24 Male February

Accidental. This man was working on a car with the

motor running in a garage.

7 43 Male March

Accidental. This man was at work on a car in a garage.

8 54 Male March

Accidental. Gas heater in a home was turned too high.
Nonfunctional heater flue.

9 83 Female March

This woman had sat near the stove with the heater door
open.

10 41 Male April

Information incomplete.

I I 20 Male October

Accidental. This man was working on a car with the

motor running in a closed garage.

12 16 Female December

This woman was seated in a car which was in a garage
with closed doors. The motor of the car was running.

13 21 Male December

Accidental. This man was working on a car with the

motor running. The garage doors were closed.

yOU'LL HEAR ABOUT . . .
the Socialization of Medicine in Manitoba

at the

IMS ANNUAL MEETING
May 13-16, 1962

Veterans Memorial Auditorium, Des Moines

(oAuMflMl

OUR PRESIDENT SAYS—

January, the first month of the year, derived its
name from that of the Roman diety Janus, pri-
marily the god of gates and doors. He was repre-
sented as having two opposite faces — one looking
ahead and the other behind. As members of the
Woman’s Auxiliary, we can better plot our course
by taking note of our past successes and failures.

Now that Nineteen Hundred and Sixty-one has
passed, here’s to you and Nineteen Sixty-two!

Be strong, that nothing may disUirb your peace
of mind!

Talk health and happiness to every person you
meet.

Cherish each friend.

Think only of the best, work only for the best,
and expect only the best.

Be just as enthusiastic for the success of others
as you are for your own.

Forget the mistakes of the past, and press on to
greater achievements in the future.

Give so much time to self-improvement that
you will have no time to criticize others.

Be too big for worry, too noble for anger, too
strong for fear, and too happy to acknowledge the
presence of trouble!

— Gertrude F. Kilgore, President

Dr. and Mrs. Charles H. Flynn, formerly of
Clarinda, are now living at 631 Meadowlark Lane,
Cheyenne, Wyoming. Mrs. Flynn (Esther), a past
president of the Woman’s Auxiliary to the Iowa

AMEF Note Paper and Envelopes
$1.00 per pack of 10 each
Order from

Woman's Auxiliary
529-36th Street
Des Moines 1 2, Iowa

Proceeds will be donated to the American
Medical Education Foundation

Medical Society, will be greatly missed by all of
us, and she says she would like especially to hear
from her friends in Iowa.

SPEAKING OF LEGISLATION

Mrs. H. G. Ellis, Legislative Chairman, encloses
a copy of her letter “Have You Heard” with each
mailing of woman’s auxiliary news reprints. It
contains up-to-the-minute information on the sta-
tus of the King-Anderson Bill, and on plans for
defeating it. Be sure to read this concise orienta-
tion on legislation that will come up when Con-
gress reconvenes. If you have any questions, do
write to Mrs. Ellis, at 5504 Shriver Avenue, Des
Moines 12, or offer your assistance to your own
county medical society.

Mrs. Ellis would also like to hear of the plans
for legislative activity in your county.

A SAFETY PROGRAM FOR YOUR COMMUNITY

Auxiliary members who belong to various other
organizations have enviable opportunities to guide
and take responsibility for safety programs in
those groups, and to help create effective educa-
tional programs in the broad field of safety. Skilled
communication, to a large degree, will help build
a successful safety program in your town.

Determine which hazard is the greatest menace
in your community. Once this has been decided
upon, try to remove it through all of the means
at your disposal. If the objective can’t be attained
through a joint endeavor with other organizations,
let your Auxiliary — the doctors’ wives — set an
example.

Pick your project, organize your campaign, and
then get each member to participate. Perhaps in
your area one of the following is a matter of major
concern: traffic safety, including driver education,
pedestrian safety and bicycle safety; home safety,
including child safety at the dangerous age, poison
control, senior-citizen safety and prevention of
home fires; public safety, including all phases of
water safety.

When you plan your safety program, your Safety
Chairman will be happy to assist you with mate-
rials and ideas. Write to her, Mrs. Ralph Moe,
Griswold.

Journal of Iowa Medical Society

January, 1962

COUNTY AUXILIARIES

Black Hawk

The Black Hawk County Auxiliary’s November
meeting was held at the home of Mrs. Lewis
Zager, 121 Kenway Road, Waterloo. That meeting
served as the kick-off for the ticket sale for the
annual Medicine Ball, to be held at Electric Park
Ballroom on February 7. A full report of that
event will be carried in a later issue of woman’s

AUXILIARY NEWS.

Craig D. Ellyson, M.D., of Waterloo, was guest
speaker at the November meeting of the Auxiliary,
discussing medical legislation. An auction sale
was also conducted, with proceeds going to the
American Medical Education Foundation.

Buchanan

The Woman’s Auxiliary to the Buchanan County
Medical Society held a benefit card party Novem-
ber 18 at Hotel Pinicon. Various card games as
well as chess were played. Two door prizes and a
number of game-score prizes were given.

The proceeds from the sale of tickets will be
used at the county level. Some of the projects
planned for the year are: individual Christmas
gifts for the people at the Buchanan County Home;
county-level prizes for the winners of the essay
contest on “The Advantages of Private Medical
Care” or “The Advantages of the American Free
Enterprise System Over Communism”; and a
continuation of the providing of Christmas gifts
for the children at the Independence Mental
Health Institute, as the benefit funds permit.

The general chairman in charge of the benefit
was Mrs. Selig M. Korson, and each other mem-
ber of the Auxiliary worked on a committee that
helped to make the event a great success.

Clay

The Woman’s Auxiliary to the Clay County
Medical Society was awarded a Certificate of Ap-
preciation by the Clay County Association for
Retarded Children at its annual awards and appre-
ciation dinner on November 14.

The citation reads: “For helping to assure suc-

cess of National Retarded Children’s Week and
for providing opportunities for Rehabilitation and
Achievement for Children who are mentally re-
tarded.”

The certificate was signed by the president,
Mrs. G. E. Pullen, of Spencer, and was given in
recognition of the work the Auxiliary did in
coordinating the first sale of the handicrafts of
these children, with the Craft and Hobby Sale
for Crippled and Handicapped Children and
Adults, held at the Clay County Fair, in Sep-
tember.

The award was accepted for the Auxiliary by
Mrs. Dean H. King, and will be mounted in the
permanent records of the Auxiliary.

Lee

The North Lee County Medical Auxiliary met
on Tuesday, December 5, for a ten-o’clock coffee
at the home of Mrs. A. C. Richmond, in Fort Mad-
ison. The newly-elected officers were introduced:
president, Mrs. Frank Poepsel; vice-president, Mrs.
Robert Murphy; secretary-treasurer, Mrs. Miles
Archibald. Three new members were also pre-
sented: Mrs. Jaime Polit, Mrs. James Healy and
Mrs. Archibald. The guests included the wives of
local dentists and pharmacists, and Mrs. Robert
Smith, of Donnellson, women’s chairman of the
Farm Bureau.

Ronald Reagan’s record “Speaking Up for Med-
icine” was played as a part of the afternoon pro-
gram.

Mahaska

The Woman’s Auxiliary to the Mahaska County
Medical Society held a one-o’clock luncheon meet-
ing at the Downing Hotel on Tuesday, November
28. Mrs. Kenneth Lemon presided at the business
meeting.

Plans were made for the Christmas party for
the Mahaska County Hospital staff, to be held
Thursday, December 21, from one to five in the
afternoon at the Elmhurst Country Club. The
Auxiliary members undertook to decorate, to get
presents for the staff members and to serve as
hostesses.

Also, gifts of food and presents were arranged
so as to pi'ovide a Christmas for a needy family,
with the Auxiliary contributing a turkey.

WOMAN’S AUXILIARY TO THE IOWA MEDICAL SOCIETY

President — Mrs. B. F. Kilgore, 5434 Woodland, Des Moines 12
President-Elect — Mrs. A. C. Richmond, 1132 Avenue A, Fort
Madison

Recording Secretary — Mrs. F. L. Poepsel, West Point
Corresponding Secretary— Mrs. N. W. Irving, Jr., 4916 Har-
wood Drive, Des Moines 12

Treasurer — Mrs. J. H. Matheson, 4321 California Drive, Des
Moines 12

Editor of the news — Mrs. Herbert Shulman, 101 Martin Road,
Waterloo

77i&,

IOWA MEDICAl SOCIETY

IN THIS ISSUE:

• Frostbite of the Extremities: A Review
of Current Therapy, page 53

• Urological Management of Patients
With Spinal Cord Injury and
Disease, page 56

Aneurysm of the Splenic Artery,
page 72

Differential Diagnosis of Jaundice in
a 13-Year-Old Boy — S.U.I. Clinical
Pathologic Conference, page 74

Efficacy of propionyl erythromycin and its lauryl sulfate salt in
803 patients with common bacterial respiratory infections.

[

Tonsillitis*

g||| , - 1

92.3%

235 patients 'j /

Acute Streptococcus Pharyngitis*

88.3%

317 patients

[

Bronchitis* (Bacterial Complications)

95.3%

85 patients

Pneumonia*

88.6%

166 patients J

‘References available on request.

U.C. MEDICAL CENTER LIBRARY

FEB 8 1962

San Francisco, 22

speed

recovery

The usual dosage for infants and children under twenty-five pounds is 5 mg. per
pound every six hours; for children twenty-five to fifty pounds, 125 mg. every six hours.

For adults and children over fifty pounds, the usual dosage is 250 mg. every six hours.
In more severe or deep-seated infections, these dosages may be doubled.

Available as: Pulvules® — 125 and 250 mg. f; Oral Suspension — 125 mg. f per 5-cc.
teaspoonful; and Drops — 5 mg. f per drop.

This is a reminder advertisement. For adequate information for use, please consult manufacturer's literature. Eli Lilly and
Company, Indianapolis 6, Indiana.

Ilosone® (erythromycin estolate, Lilly) (propionyl erythromycin ester lauryl sulfate)
fBase equivalent

FEBRUARY, 1962

when urinary
tract

infections
present
a therapeutic
challenge . . .

(chloramphenicol, Parke-Davis)

Often recurrent . . . often resistant to treatment, urinary tract infections are among the most
frequent and troublesome types of infections seen in clinical practice.1-2 In such infections,
successful therapy is usually dependent on identification and susceptibility testing of invad-
ing organisms, administration of appropriate antibacterial agents, and correction of obstruc-
tion or other underlying pathology.

Of these agents, one author reports : “Chloramphenicol still has the widest and most effective
activity range against infections of the urinary tract. It is particularly useful against the
coliform group, certain Proteus species, the micrococci and the enterococci.”1 CHLOROMYCETIN
is of particular value in the management of urinary tract infections caused by Escherichia
coli and Aerobacter aerogenes .3 In addition to these clinical findings, the wide antibacterial
range of Chloromycetin continues to be confirmed by recent in vitro studies.4-6

CHLOROMYCETIN (chloramphenicol, Parke-Davis) is available in various forms, including Kapseals® of 250 mg.,
in bottles of 16 and 100. See package insert for details of administration and dosage.

Warning ; Serious and even fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia,
granulocytopenia) are known to occur after the administration of chloramphenicol. Blood dyscrasias have
occurred after both short-term and prolonged therapy with this drug. Bearing in mind the possibility that
such reactions may occur, chloramphenicol should be used only for serious infections caused by organisms
which are susceptible to its antibacterial effects. Chloi-amphenicol should not be used when other less poten-
tially dangerous agents will be effective, or in the treatment of trivial infections, such as colds, influenza, or
viral infections of the throat, or as a prophylactic agent. Precautions : It is essential that adequate blood
studies be made during treatment with the drug. While blood studies may detect early peripheral blood
changes, such as leukopenia or granulocytopenia, before they become irreversible, such studies cannot be
relied upon to detect bone marrow depression prior to development of aplastic anemia.

References: (1) Malone. F. J.. Jr. : Mil. Med. 125 :836. 1960. (2) Martin, W. J. ; Nichols, D. R., & Cook, E. N. : Proc. Staff Meet Mayo Clin
34:187, 1959. (3) Ullman, A.: Delaware M. J. 32:97, 1960. (4) Petersdorf, R. G. ; Hook, E. W. ;

Curtin, J. A., & Grossberg, S. E. : Bull. Johns Hopkins Hosp. 108:48, 1961. (5) Jolliff, C. R. ;

Engelhard, W. E. ; Ohlsen, J. R. ; Heidrick, R J., & Cain, J. A.: Antibiotics & Chemother. 10:

694, 1960. (6) Lind, H. E. : Am. J. Proctol. 11:392, 1960. 6896|

PARKE-DAVIS

PARKS. DAVIS A COMPANY. 0»tm< 37. Mkhfria \

Vol. HI FEBRUARY, 1962 No. 2

CONTENTS

SCIENTIFIC ARTICLES

Frostbite of the Extremities: A Review of Cur-
rent Therapy

Adrian E. Flatt, M.D., Iowa City 53

Urological Management of Patients With Spinal
Cord Injury and Disease
Dieter Kirchheim, M.D., and William D. De-
Gravelles, Jr., M.D., Des Moines 56

Aneurysm of the Splenic Artery
Clarence J. Mikelson, M.D., Waterloo .... 72

State University of Iowa College of Medicine
Clinical Pathologic Conference 74

EDITORIALS

The Brighter Side 85

Prophylaxis for Marital Difficulty 85

Medical Self-Help Training Course 86

Acne 86

Smoking Habits 87

Pulmonary Sarcoidosis 88

SPECIAL DEPARTMENTS

Coming Meetings 84

President’s Page 93

Journal Book Shelf 94

Iowa Association of Medical Assistants ... 97

In the Public Interest Facing page 98

Iowa Chapter of the American Academy of Gen-
eral Practice 99

Doctor’s Business 103

State Department of Health 104

Woman’s Auxiliary News 107

Month in Washington xxx

Personals xxxiii

Deaths lii

MISCELLANEOUS

Cortisone in Kerosene Pneumonia 89

County Societies to Get New Public Service Ads 91

New Physician’s Guide on Anticoagulants ... 91

Hazards in Do-It-Yourself Laundries .... 91

In Memoriam: Lester Davis Powell, M.D. ... 92

Film on Stroke Diagnosis 92

Education in Hospital Costs 96

The Incidence of Peptic Ulcer 98

Excess Mortality Associated With Epidemic In-
fluenza 101 j

The U. S. Food and Drug Administration ... 1

IOWA MEDICAL SOCIETY

EDITORS

Dennis H. Kelly, Sr., M.D., Scientific Editor Des Moines

Edward W. Hamilton, Ph.D., Managing Editor

Des Moines

SCIENTIFIC EDITORIAL PANEL

Walter M. Kirkendall, M.D Iowa City

Floyd M. Burgeson, M.D Des Moines

Daniel A. Glomset, M.D. Des Moines

Robert N. Larimer, M.D Sioux City

Daniel F. Crowley, M.D Des Moines

PUBLICATION COMMITTEE

Samuel P. Leinbach, M.D Belmond

Otis D. Wolfe, M.D Marshalltown

Cecil W. Seibert, M.D Waterloo

Richard F. Birge, M.D., Secretary Des Moines

Dennis H. Kelly, Sr., M.D., Editor Ex Officio Des Moines

Address all communications to the Editor of the Jour-
nal, 529-36th Street, Des Moines 12

Postmaster, send form 3579 to the above address.

Second-class postage paid at Fulton, Missouri, and (for additional mailings) at Des Moines, Iowa. Published monthly by the
Iowa Medical Society at 1201-5 Bluff Street, Fulton, Missouri. Editorial Office: 529-36th Street, Des Moines 12, Iowa. Subscrip-
tion Price: $3.00 Per Year.

Frostbite of the Extremities

A Review of Current Therapy

ADRIAN E. FLATT, M.D.
Iowa City

The treatment of frostbite was the subject of
two papers and considerable discussion at the
1961 Forum on Fundamental Surgical Problems of
the American College of Surgeons. Dr. William J.
Mills, of Anchorage, Alaska, made a comprehen-
sive presentation on the subject at that meeting,
and also has recently published three papers re-
porting his work in this field during the last six
years. The following report of current views on
frostbite therapy is based largely on Dr. Mills’ ex-
tensive experience, but also on the limited number
of cases that have been treated in recent years at
University Hospitals, Iowa City.

Frostbite, by definition, is a result of the cooling
of tissues to the point of ice-crystal formation. It
is therefore both a physical and a biochemical in-
jury. The physical injury is the result of cell-rup-
ture that has taken place during the growth of the
ice crystals. Meryman has shown that the sizes of
these crystals are related to the rates of freezing
and the lengths of time in which the tissues are
maintained in a partially frozen state. The bio-
chemical injury to the cells is partially produced
by the dehydration, which causes both protein de-
naturation and a paralysis of enzyme activity. Sev-
eral investigators believe that reduced circulation
in the area is responsible for further tissue dam-
age, but it is probable that this effect is seen large-
ly in a tissue-temperature range of +5° to +15°C.

By the time the frostbitten patient reaches med-
ical care, the tissue damage has already occurred,

Dr. Flatt, a fellow of the American and of the Royal
Colleges of Surgeons, is an associate professor of orthopedic
surgery at the S.U.I. College of Medicine.

and therapy must therefore be directed to limiting
the damage.

Inevitably, some tissue must have been lost, but
proper care at this stage will prevent further loss
from secondary changes.

IMMEDIATE TREATMENT

Primary treatment consists of general sup-
portive care, for the patient is frequently in a
state of hypothermia, and of local care to the
frozen tissues. General body temperature is best
raised by the application of external warming de-
vices and by the administration of warm fluids by
mouth.

The frozen limb must be thawed by rapid re-
warming at a temperature of 42°C. There is now
ample experimental and clinical evidence that the
traditional slow-thawing methods such as immer-
sion in ice water or rubbing with snow produce
more tissue damage than occurs if the tissues are
rapidly rewarmed.

Hot-air rewarming is particularly dangerous,
since the tissue temperature cannot be readily
controlled, and the limb, in effect, is being cooked
as in an oven. The correct way to rewarm a frost-
bitten extremity is to immerse it in a constant-
temperature water bath held at 42°C. Although
this temperature has been found to give the best
results, a degree or two of latitude either side of
that figure is permissible (110° to 118°F.). This
method of rewarming is painful to the patient and
may appear to produce a deterioration in his con-
dition, for the thawing of the area produces a
peripheral hyperemia around the area of tissue
death, and blebs or bullae may appear beneath
the superficial epithelial layers. Sedatives are fre-
quently indicated to control the discomfort during
the rewarming process, and are often indicated

Journal of Iowa Medical Society

February, 1962

to allay fear and to control the more irrational
patients.

Although there is little clinical difficulty in
establishing the diagnosis of frostbite, there are
great difficulties in predicting the ultimate extent
of the injury. In the past, there have been at-
tempts to classify frostbite injuries in degrees
similar to those advocated for burns. Such esti-
mates, however, are almost invariably wrong, and
in fact serve no useful clinical purpose. Modern-
day classification of burns has been narrowed to
either partial or complete epithelial loss, and frost-
bite should be classified similarly, either as su-
perficial or deep tissue death. Mills points out
that even the predictions of physicians experienced
in the care of frostbite are not very often borne
out by the final results. In fact, even the classifica-
tion of frostbite injuries as either superficial or
deep has little clinical value except in the mildest
cases. Initial treatment and subsequent care are
identical in all cases, and there is no evidence that
therapy should be varied according to the degree
of the frostbite.

A factor that has proved to be of help in the
prognosis has been body temperature. Where there
has been a marked fall in general body tempera-
ture, the local tissue damage does appear to have
been greater than in cases where the body tem-
perature has been maintained. It therefore is rea-
sonable to give a very guarded prognosis in pa-
tients showing marked hypothermia.

IMMEDIATE CARE

Once the affected sites have been thawed, the
clinical problem becomes one of preventing in-
fection in the area and maintaining circulation
to the devitalized tissues. Occasionally, there are
associated injuries such as fractures or disloca-
tions that may complicate therapy. Treatment of
such conditions should border on the conservative,
and every effort must be made to maintain cir-
culation in the area. Dislocations should be re-
duced and fractures placed in reasonable align-
ment, but maintenance of those positions by trac-
tion, tight casts or even fixation by open operation
may compromise the circulation and should be
avoided.

It is vital to explain to the patient that the key
to subsequent therapy is “masterly inactivity,”
and that he should expect areas of necrosis and
gangrene to appear. He must be made to realize
that superficial death of tissues is inevitable and
that this death will be more widespread than that
which is occurring in the deeper tissues. Epithe-
lium will survive beneath the superficial eschar,
provided that it does not become infected, and
when separation occurs, the area of deep or full-
thickness loss will be much less than could have
been assumed by judging the extent of the super-
ficial necrosis.

As in any other gangrenous state, it is of great
importance to prevent the onset of secondary in-
fection. The necrotic areas should be exposed so

that an eschar is formed, and they should be kept
dry at all times. Deliberate puncture of the blebs
should be avoided, since it would convert a sterile
area into a potentially infected one. The blebs
should be allowed to dry and absorb by them-
selves, and they will need careful nursing at-
tention, in the early days, to prevent accidental
rupture. Routine chemotherapy is unnecessary.
Antibiotics should be reserved for use in cases in
which secondary infection has become established,
and in which cultures have shown that sensitive
organisms are present.

Active exercises should be encouraged, since
they will help to prevent stiffness, will improve
muscle tone and will encourage local circulation.
Mills says that whirlpool baths are helpful in the
later stages of intermediate care because they ap-
pear to increase local circulation, to cause a rapid
diminution of local edema and to encourage ex-
ercising because of the support supplied by the
water.

Sympathetic block and sympathectomy have
been advocated as helpful in the early treatment
of frostbite, but there does not appear to be any
good evidence that such treatment is of use.
de Jong and his colleagues reported a series of
sympathectomies performed on frostbite victims
during the bad winter of 1960-1961 in New York
City. Unfortunately, the data that they presented
at the College of Surgeons meeting did not, to my
way of thinking, appear to justify their conclu-
sion that early regional sympathectomy promotes
healing, or that amputation in cold injuries is un-
necessary if local therapy is assiduous. I would
agree with their recommendation that long-term
follow-up should be maintained so that it can be
determined whether the late sequelae of frostbite
can be avoided through early sympathectomy.

Of equally doubtful value are vasodilator and
anticoagulant drugs. As has been pointed out, the
initial trauma of the freezing has defined the
area of damage, and such drugs are unlikely to
have any effect upon subsequent thrombosis of
blood vessels or vascular sludging within this area.

As the days pass, the area of definitive loss
becomes established, and the superficial layers of
the periphery begin to separate. At that point,
whirlpool baths are often particularly helpful in
performing a very gentle debridement. Only those
tissues which have already begun to separate
should be removed. Wholesale debridement of tis-
sue should never be performed, and debridement
in the early days after freezing, before the area
of loss has been defined, is absolutely contrain-
dicated. It must be repeated that the extent of
survival of deep tissues is astonishing and usually
far exceeds the physician’s early expectations.
Mills and his colleagues have stated that “we con-
sider it overwhelmingly demonstrated here that of
all the factors in the treatment of frostbite which
may influence the result, premature surgical in-
tervention by any means, in any amount, is by

Vol. LII, No. 2

Journal of Iowa Medical Society

far the greatest contributor to a poor result of any
variable analyzed.”

Although wholesale debridement has been con-
demned, it should be pointed out that limited ex-
cision of eschar and dead tissue can be helpful
under certain circumstances. The exposure treat-
ment of burns of the extremities carries with it
the risk of strangulation of blood supply by con-
traction of circumferential scarring or eschar for-
mation. The same problem can develop during the
first few weeks of frostbite healing. Thus, the
circulation of a digit and the blood supply to the
intrinsic muscles of hand or foot can be restrict-
ed. Limited excision of eschar will ensure relief
of the constriction and the preservation of as good
a blood supply as possible to those areas.

Active movement of digital joints is sometimes
prevented by tight eschar, and a unilateral or bi-
lateral incision over the joint may allow a greatly
increased range of movement. However, every
time the protective layer of dry eschar is broken,
the deeper poorly-viable tissues are exposed to the
risk of an infection that may compromise their
healing.

When frank infection is demonstrable, one
should treat it along the standard lines of culture,
using the appropriate antibiotic, draining any
pockets of pus and excising frankly gangrenous
areas. Surgical treatment of the infection should
tend to be conservative, and should be directed
more at helping the local tissues combat the in-
fection than at radically excising the whole in-
fected area.

LATE CARE

If actual tissue freezing has occurred, it appears
inevitable that there will be some persistent demon-
strable deficiency, varying from frank amputation
to digital-pulp atrophy and sensory disturbances.

When digits have been killed by freezing, they
will eventually demarcate and drop off, and there
should be no hurry in aiding their amputation.
The optimum time for surgical interference is dur-
ing the third month (60-90 days) after freezing.
By this time, all tissues that can possibly survive
will have reestablished their circulations, and
amputation should be performed at the most distal
level possible. Although the bone should be cut
back to a bleeding end, all possible length should
be retained. One should place small skin grafts on
granulating stumps, rather than cut back the bone
far enough to allow the use of formal skin flaps.
If ascending, uncontrollable infection forces am-
putation at a higher level, a guillotine-type am-
putation must be done, and the stump allowed to
granulate. Skin grafts to the granulating area act
as an excellent dressing, provide early epithelial
cover and reduce the amount of scarring. But they
do not usually preclude a later, formal revision of
the stump.

The intrinsic muscles of the hand and foot are
particularly sensitive to periods of ischemia. Many
cases of frostbite will show varying degrees of
fibrosis of the muscle bellies as a result of this

ischemia. Such interference with intrinsic muscle
action can seriously handicap both hand and foot
function, and appropriate orthopedic procedures
may be necessary in order to correct the func-
tional handicap.

In Iowa, we tend to see more residual disability
from frostbite of the hands than of the feet. Cir-
culatory deficiencies, sensory disturbances and
pulp atrophy of the fingers are great handicaps
to people whose occupations force them to put
their hands in jeopardy during subsequent win-
ters.

Although early proximal sympathectomy does
not appear to help the treatment of frostbite, it is
possible that late distal sympathectomy may have
some value. The operation should be considered
experimental, and long-term results are not yet
available. In two such cases in recent years, we
have been able to relieve the symptoms to a con-
siderable extent and to prevent amputation by
performing a distal sympathectomy at the level of
the origin of the digital arteries in the palm. Such
surgery appears to paralyze the tone of the digital
arteries permanently, and we have been able to
show that increased skin temperatures have been
maintained through a subsequent winter.

CONCLUSION

In conclusion it should be emphasized that the
care of severe cases of frostbite is a long-drawn-
out process calling for the absolute cooperation of
the patient, nursing of the highest order, and con-
siderable therapeutic restraint on the part of the
physician. In these cases, the patient is confined
to bed for many weeks, and has to rely on others
for help in all toilet necessities and recreational
activities. It is inevitable that such patients will
go through periods of despondency which can be
relieved only by the devoted care of nurses and
physicians. Surgical procedures are rarely in-
dicated in the preliminary stages of frostbite care.
Early debridement could be dangerous, and early
amputation would be prodigal. Both must be post-
poned unless the indications are overwhelming.

ACKNOWLEDGEMENT

I should be held entirely responsible for the
views expressed in this paper, but I wish public-
ly to record my grateful thanks to Dr. William J.
Mills, Jr. and his colleagues for their permission
to quote freely from their publications. Their pa-
pers, together with information I gained during
conversations with Dr. Mills, have formed the
basis for this review.

REFERENCES

1. de Jong, P., Golding, M. R., Sawyer, P. N., and Weso-
lowski, S. A.: Recent observations on therapy of frostbite.
A.C.S. Surgical Forum, 12:444-445, 1961.

2. Meryman, H. T. : Tissue freezing and local cold injury.
Physiological Reviews, 37:233-251, (Apr.) 1957.

3. Mills, W. J., Jr., and Whaley, R.: Frostbite: experience
with rapid rewarming and ultrasome therapy. Part I. Alaska
Medicine, 2:1-4, 1960.

4. Mills, W. J., Whaley, R., and Fish, W.: Frostbite ex-
perience with rapid rewarming and ultrasome therapy. Part
II. Alaska Medicine, 2:114-124, 1960. Part III. Ibid., 3:28-36,
1961.

Urological Management of Patients
With Spinal Cord Injury and Disease

DIETER KIRCHHEIM, M.D., and
WILLIAM D. DeGRAVELLES, JR., M.D.
Des Moines

Much progress has been made over the past 20
years in the care of patients with spinal-cord in-
jury and disease. Antibiotics and other medica-
tions, plus the proved success of physical rehabili-
tation measures, have reversed the pessimism that
formerly prevailed among the personnel and in the
institutions caring for these patients. Present-day
concepts demand active, aggressive treatment to
bring these people to maximal functional and
health status culminating, in many instances, in in-
dependent living and, ultimately, employment.

Because of the number of body systems affected
by spinal-cord damage, successful management of
these patients can be achieved only through the
cooperative efforts of a team of medical and sur-
gical specialists with help from certain paramedical
personnel. Urological management and follow-up
are very important to these individuals, since their
longevity and general state of health are often
governed by the health of their kidneys and uri-
nary tracts. All of the benefits of early medical and
surgical care and of a physical rehabilitation pro-
gram can be lost through the unexpected advent
of renal insufficiency, months or years after the
injury or after the onset of the spinal-cord disease.

It is hoped that this paper will help the non-
urologist to understand the urological problems
seen in the paraplegic or quadriplegic, so as to
arrive at an early diagnosis in patients of these
types, and thus to prevent serious urinary com-
plications in many instances.

The case reports that will be presented are of
patients seen and treated at the Younker Memorial
Rehabilitation Center of Iowa Methodist Hospital,
Des Moines. All spinal-cord-injury patients ad-
mitted to the Center undergo complete urological
work-ups. The physical rehabilitation program is
begun only after the urological survey has been
completed, after consultations with other special-
ists have been held, as indicated, and after the
necessary surgical and medical procedures have
been accomplished or are well under way.

NEUROANATOMy AND NEUROPHYSIOLOGY
OF MICTURITION

The following is just a short outline of the per-
tinent facts about the neuroanatomy and neuro-
physiology of micturition. For more detailed in-
formation, the reader is referred to the excellent
monographs by Emmett3 and Bors.1

In contrast to skeletal muscle, the smooth-muscle
structures of the urinary conducting organs (renal
calyces and pelves, and ureters) can function in
the apparent absence of innervation. Thus, spinal-
cord injury or disease seems to have no primary
effect upon the functions of the kidneys and ureters.
However, with its internal and external sphincter

& ejaculatory duct orifices

Figure I. Innervation of bladder (detrusor muscle) and
of the internal and external sphincters. The sensory afferents
are on the right hand side and motor nerves on the left
hand side of the sketch.

Vol. LII, No. 2

Journal of Iowa Medical Society

mechanism, the bladder contains both smooth and
skeletal muscles, which are innervated by auton-
omous and somatic fibers. Figure 1 depicts the
present concept of the innervation of the bladder
and its sphincters. The sympathetic innervation
(presacral nerve) has been omitted, since stimula-
tion or interruption of these fibers can give con-
troversial results, and since either one seems to
have much less importance than does innervation
by the parasympathetic pelvic and the somatic
pudendal nerves.

Motor Nerves. The parasympathetic pelvic
nerves originate from horns of S2-4. These consist
of pre- and postganglionic nerves which synapse
in intra- or extramural bladder ganglia. They form
loose bundles and cannot be anatomically identi-
fied as distinct nerve cords. They innervate the
detrusor muscle of the bladder and the internal
vesical sphincter, which actually is formed by an
interlacing of detrusor muscle fibers at the vesical
neck.

The somatic pudendal nerves also originate from
horns of S2-4, and reach the external sphincter
muscle and the pelvic floor muscles via Alcock’s
canal.

Figure 2. Lewis recording cystometer. Saline is run from
a 1,000 cc. intravenous container at a level of 45 cm. above
the level of the symphysis into the manometer through the
inlet valve indicated by the arrow. It leaves the manometer
at the outlet valve ( x ) , and flows through a rubber tube
to the Foley catheter in the patient's bladder. Here, the
infusion bottle has been lowered so as to permit its inclusion
in the picture. Instead of this refined apparatus, a simple
water manometer like the one used in spinal fluid manometry
can be employed. It would be connected by a glass Y-tube
to the infusion bottle on one side and to the Foley catheter
on the other.

Sensory Nerves. (1) Exteroception. Afferents of
mucosal sensation to touch and pain which reach
the spinal cord via spinal ganglia and posterior
roots are contained within the parasympathetic
pelvic nerves and, to a much lesser extent, within
the sympathetic presacral nerves.

(2) Proprioception. The desire for micturition
originates in the proprioceptors of the detrusor
either when the intravesical pressure has reached
the threshold of the detrusor’s ability to stretch
(tone), or when it is increased by the volitional
intent to void. The impulses are mediated via
pelvic nerves, spinal ganglia, posterior sacral roots,
and spinothalamic tracts to the thalamus, subcor-
tex and cortex. The sensation that micturition is
imminent is probably caused by stimrdation of the
proprioceptors in the striated pelvic-floor muscula-
ture (external sphincter) and conducted along the
sensory fibers of the pudendal nerves.

Reflex Centers. Peripheral intra- and extramural
centers maintain bladder tone. They are unable to
initiate a true voiding contraction.

The sacral micturition center is located in the
S2-4 segments of the spinal cord, which corre-
sponds to the level of vertebrae LI to L2. Reflex
arcs consist of exteroceptive mucosal and proprio-
ceptive muscular afferents and autonomic efferent
limbs (Figure 1). In the absence of the inhibitory
fibers from the brain — physiologically in the in-
fant and pathologically in patients with suprasacral
spinal-cord lesions — the sacral micturition center
regulates voiding (reflex detrusor contractions,
no voluntary control).

The supraspinal (cerebral) centers affect mic-
turition chiefly by inhibiting the sacral reflex arc.
Voluntary cerebral release of this inhibition per-
mits the sacral reflex to take place and results in
a voiding detrusor contraction. The whole process
of cerebral coordination, integration and facilita-
tion is actually much more complex than we have
indicated, but it is too controversial for presenta-
tion here. The striated muscles of the external
vesical sphincter and the pelvic-floor muscles are
under the volitional control of the motor cortex.

In the normal person, a voiding detrusor con-
traction results in a practically complete emptying
of the bladder, leaving less than 30 cc. of residual
urine. He is able to initiate, postpone, interrupt
and restart voiding at will. This ability requires
not only intactness of the above-described bladder
nerves but also normal integration and coordina-
tion of the reciprocal activities of the expulsive
(detrusor) and retentive (sphincter) forces, which
are regulated by the cerebral and sacral micturi-
tion centers.

Cystometry. By plotting intravesical pressure
against intravesical volume, one can obtain a
cystometric graph. This can be done easily by using
a simple water manometer attached at right angles
to the outflow tubing of an indwelling Foley cathe-
ter. An aneroid manometer with a revolving drum
and an automatic writer (Figure 2) is somewhat
more refined and easier to use. Excretory cystom-
etry is a more physiological method than retrograde
cystometry, since the patient’s own urine flow is
used to measure intravesical pressures. However,
that method is time consuming, and leaves one in

Journal of Iowa Medical Society

February, 1962

doubt as to the exact amounts of urine present in the
bladder at various pressure readings. In retrograde
cystometry, the bladder is gradually filled either
by a continuous Murphy drip or by interrupted in-
crements of 50 cc. of saline. The cystometrograph
records the intravesical pressures (tones) during
the filling of the bladder. Voluntary detrusor con-
tractions (at 40 to 120 mm. Hg) or uninhibited
detrusor contractions (always pathological except
in the infant) can be seen as spikes above the
gradually rising graph of bladder tone. The rate of
the Murphy drip is much faster than the rate of
the patient’s own urine flow from the kidneys.
This, together with the irritation of the indwelling
Foley catheter, may cause artifacts, but cysto-
metrograms, especially serial ones, provide one a
good idea of the neurological function of the
bladder.

If, instead of a slow, continuous drip, the inter-
rupted 50 cc. increments of saline are used, the
sudden and fast inflow of each such amount raises
the manometric recording artificially. In the
normal bladder, however, the intravesical pres-
sure returns to the previous “tone” or slightly
above it within seconds after the 50 cc. increment
of saline has entered the bladder and the inflow
valve has closed. The normal bladder adjusts to
increasing intravesical volume by a very gradual
rise in intravesical pressure ranging from a few
millimeters of mercury at low fillings to 10 to 20
mm. Hg at the time of the desire to void, which
usually occurs at a filling of between 200 and 400
cc. In a neurogenic bladder, the viscus no longer
can adjust quickly to sudden changes in volume,
and this inability is reflected in a slower return to
the preexisting pressure after a 50 cc. saline in-
crement and the shutting off of the inflow valve of
the Murphy drip (Figure 3C).

Figure 3A represents three normal cystometro-
grams. Sensations such as fullness, first desire to
void, urgency and discomfort are within normal
limits. The pressure curves are relatively smooth,
gradually rising graphs, indicating normal bladder
tone and the absence of “uninhibited contractions”
of the detrusor. The vertical dotted lines at the
time of desire to void record the pressure spikes
reached by the detrusor contractions, which would
result in voiding and complete emptying. This emp-
tying requires not only normal functioning of the
detrusor but also proper coordination by the higher
micturition centers, causing reciprocal relaxation
of the sphincters and pelvic-floor muscles. Initia-
tion and control are normal, and there is “no”
(i.e., less than 30 cc.) residual urine.

Uninhibited contractions, as in a case of spinal-
cord transection at the level of D6 (Figure 3B)
are always pathological and are caused by a lack
of cerebral control over the sacral micturition cen-
ter. These uninhibited contractions may occur
frequently at low fillings of the bladder, resulting
in almost continuous spurts of urine, or they may

Figure 3A. Three cystometrograms of three patients with
normal bladder function. Bladder tones (almost horizontal
lines) stay within narrow pressure limits during filling of
bladder (0-20 mm. Hg). Perpendicular lines are voluntary
voiding contractions (between 60 and 120 mm. Hg). Note
absence of uninhibited detrusor contractions.

VOLUME — hundred cc

Figure 3B. Patient with spastic neurogenic bladder. Cord
lesion at D6. The bladder tone rises more sharply, and there
are four well-defined uninhibited detrusor contractions at
between 50 and 250 cc. fillings. This patient will manifest
clinically "active" incontinence.

take place at intervals, occurring at fillings from
100 to 250 cc. and manifesting a more efficient
“automatic reflex bladder.”

If the spinal-cord injury is at a lower level and
has destroyed the sacral micturition center or its
afferents and efferents at the level of the cauda
equina, voiding is controlled solely by the periph-
eral intra- and extramural vesical ganglia, and
by the inherent properties of smooth muscle itself
(autonomous bladder). For reasons not yet defi-
nitely explained, this usually results in a very
hypertonic (hypertrophied, trabeculated) bladder,
with inefficient detrusor contractions and large
amounts of residual urine. However, since these

Vol. LII, No. 2

Journal of Iowa Medical Society

VOLUME - hundied cc

Figure 3C. Patient with hypertonic neurogenic bladder
due to low spinal-cord injury at level L I and L 2. The
shaded areas are pressure rises from 50 cc. infusions, and
are thus not part of the pressure curve of the detrusor. Nor-
mally, the descending limb of the shaded areas is as perpen-
dicular as the ascending limb, which corresponds to the
opening and closing of the infusion valve. However, in many
neurogenic bladders the detrusor has lost its ability to adjust
quickly to changes in volume, and thus the pressure curve
returns only gradually to the base line in this graph. At a
filling of 200 cc., there is an uninhibited detrusor contraction.
This patient has no bladder sensation, and is unable to void
normally, but he can empty his bladder by abdominal pres-
sure (two spikes of 50-60 mm. Hg at a filling of 250 cc.).

Figure 3D. Hypotonic or atonic neurogenic bladder fol-
lowing shortly after spinal-cord injury. There is no bladder
sensation of filling, and bladder tone stays below 5 mm. Hg
up to a filling of 700 cc. No uninhibited reflex contraction,
and complete detrusor paralysis on attempted voiding or
straining.

0 1 2 3 4 5 6 7

VOLUME — hundred cc

Figure 3E. Hypotonic neurogenic bladder of a patient
with tabes dorsalis. Similar to the acute phase of spinal-cord
injury represented in 3D. The sensory afferents of the detrusor
and posterior spinal cord have been destroyed, and the
bladder is flaccid.

lesions are mostly at the lower dorsal or lumbar
spine, the innervation of the abdominal muscles
remains intact, and some of these patients are able
to initiate voiding by voluntary contractions of

their abdominal muscles, supplemented by manual
abdominal pressure (Crede). Figure 3C is a
cystometrogram of such a case.

UROLOGICAL MANAGEMENT OF ACUTE AND
CHRONIC STAGES OF SPINAL-CORD INJURY*

The acute or “shock” stage of the bladder in
spinal-cord injury is characterized by complete
loss of reflex activity. Figure 3D shows a typical
cystometrogram of a patient shortly after tran-
section of the spinal cord at D6, resulting in com-
plete motor and sensory paralysis. Depending upon
the severity of the spinal-cord lesion and other
factors, reflex activity below the lesion may reap-
pear after lengths of time varying from days to
months. When this occurs, the patient is said to
have entered the “chronic” or “recovery” stage of
vesical function. Maximal recovery may take as
long as 12 to 16 months following the injury. Treat-
ment during this period is aimed at preventing
complications such as urinary-tract infections,
bladder contracture and stone formation, and at
facilitating the return of bladder function through
supportive measures (bladder training). Correc-
tive surgery ( transurethral resection of vesical
neck and prostate, nerve resections, plastic pro-
cedures) is not undertaken until no further re-
covery of bladder function is expected.

To measure the return of bladder function, cys-
tometrograms are done every four to eight weeks.
As soon as the patient is over the initial traumatic
episode and has stabilized medically, a complete uro-
logical work-up is done, including urinalysis, urine
culture and sensitivities, B.U.N., intravenous pyelo-
gram, retrograde cystogram and, if indicated, cys-
toscopy, retrograde pyelography and cinefluoros-
copy.

Following spinal-cord injury and during the
period of recovery, the urological management
consists of:

1. Continuous urethral catheter drainage to pre-
vent over distention of the paralyzed bladder. When
the cystometrogram shows evidence of good re-
flex activity, bladder training is begun (see No. 6,
below).

2. High oral fluid intake to promote drainage
and to decrease the incidence of urinary calculus
formation (3,000-4,000 cc. daily).

3. Early mobilization of the patient to combat
demineralization and improve urinary drainage.

4. Proper catheter care. The Foley urethral cath-
eter is changed weekly or more often if necessary,
and is irrigated twice daily with normal saline or
one of the antiseptic irrigating solutions such as 2
per cent boric acid or 1:10,000 potassium perman-
ganate. To decrease the incidence of peno-scrotal-
angle fistulas, the Foley catheter is taped to the
abdomen, thus straightening the curvature of the
anterior urethra at the peno-scrotal angle. If the

*This is the management used by Dr. Kirchheim and his
associates Drs. C. W. Latchem and E. T. Burke. Urological
management of spinal-cord disease is similar.

Journal of Iowa Medical Society

February, 1962

Foley catheter becomes easily encrusted with cal-
careous precipitations or if urinary calculi are
forming, we use 10 per cent renacidin solution to
irrigate the catheter. Using renacidin may also cut
down the frequency of catheter changes. As is in-
dicated in No. 7 of the following case reports, early
urinary calculi may be softened, broken up and
dissolved through renacidin irrigation. For neph-
rostomy or ureterostomy tubings, a weaker (5 per
cent) renacidin solution is recommended.

5. Prevention and treatment of urinary-tract in-
fections. Most patients with indwelling catheters
harbor pathogenic microorganisms in their urine,
most commonly strains of the E. coli group, Aero-
bacter, Proteus, Pseudomonas or enterococcus (Str.
faecalis). It is practically impossible to sterilize the
urines of these patients for any length of time. In
spite of bacteriuria, the urine remains clear, and
microscopically contains fewer than 10-20 white
blood cells per high-power field. Evidently a local
tissue-immunity develops. If these bacteria cross
the local tissue barrier and cause renal and/or
systemic infection characterized by increased
pyuria, fever and chills, an appropriate wide-spec-
trum antibiotic is indicated. According to the sen-
sitivity studies and clinical responses in our ex-
perience, the most frequently useful antibiotics
have been Declomycin (demethylchlortetracy-
cline), Chloromycetin (chloramphenicol), Fura-
dantin and the other tetracyclines (Cosa-tetracyn,
etc.). In resistant proteus and pseudomonas infec-
tions Kantrex (kanamycin), 500 mg. intramus-
cularly twice daily, and Coly-mycin, 150 mg. intra-
muscularly daily, gave good results in several
cases. Three severe staphylococcal infections that
were resistant to penicillin, staphylocillin, eryth-
romycin and Albamycin (novobiocin) responded
well to Vancocin (vancomycin), 500 mg. in 250 cc.
of saline intravenously every six hours. If the
spiking fever and chills persist in spite of appro-
priate antibiotic therapy, one must look for an ob-
structive, stasis-producing lesion such as a blocked
catheter, bladder-neck obstruction, stones, ureteral
kink, stricture, diverticulum, perinephric abscess
or obstruction by extrinsic pressure. Once the ob-
struction has been relieved, the signs of pyelone-
phritis and systemic infection usually subside with-
in several days.

We do not favor the continuous administration
of wide-spectrum antibiotics as a prophylactic
measure. If, in spite of the above measures, the pa-
tient has frequent urinary-tract infections, the less
expensive sulfonamides (Gantrisin, Thiosulfil
Forte) and Mandelamine are preferable for inter-
mittent prophylactic therapy. In contrast with the
wide-spectrum antibiotics, these drugs do not de-
stroy the normal bowel flora, and do not cause
staphylococcal overgrowth of the intestines with
severe complications such as staphylococcal (pseu-
domembranous) enteritis. The pH of the urine is
checked at intervals. The commonest urinary cal-

culi, especially in an infected urine, are calcium,
ammonium phosphate and carbonate compounds,
which precipitate more easily in alkaline urine.
Several urinary pathogens, chiefly the proteus
group, split urea and form ammonia, thus render-
ing the urine alkaline. In some instances, the ad-
ministration of Mandelamine (1.0 Gm. q.i.d.) and
ammonium chloride (0. 5-1.0 Gm. q.i.d.) will reduce
the proteus infection and shift the urinary reaction
toward the acid side. Some of the newer antibiotics
such as kanamycin (Kantrex), Coly-mycin and
Seromycin may be helpful against certain proteus
strains. Some cases, however, are refractory to
acidification and antibiotics. Since prolonged acid-
ification therapy with ammonium chloride may
cause demineralization and osteoporosis, it is pref-
erable to use this drug only intermittently. Acid
ash diets have been disappointing, and diet restric-
tions are hard on these patients.

6. Bladder training. As soon as the cystometro-
gram shows recovery of detrusor function, the
urethral catheter is clamped and released at one-
to two-hour intervals during the daytime. This is
done in order to distend the bladder, thus prevent-
ing contracture, and to induce certain rhythmic
reflex contractions. This “simplified bladder train-
ing” has replaced the more complicated forms of
tidal drainage at many institutions. During periods
of urinary-tract infection with marked pyuria and
fever, and in patients with persistent ureteral re-
flux, the catheter should not be clamped.

As soon as there is a significant amount of re-
covery of detrusor function, as determined by
serial cystometrograms, an attempt is made to re-
move the urethral catheter. After its removal, a
variety of impaired bladder functions can be seen.
At one end of the spectrum is the patient with an
incomplete cord lesion who regains normal or al-
most normal bladder function within several
months after injury. At the other end is the patient
with a more severe spinal-cord involvement who
urinates involuntarily, in frequent spurts, who
stays continuously wet and who retains urine.
Such an individual is subject to urinary stasis, in-
fection and stone formation. There is also the oc-
casional patient who is unable to void at all be-
cause of hypertrophy and spasticity of the internal
and/or external vesical sphincter.

SYMPTOMATOLOGY

Because there are various forms of neurogenic
vesical dysfunction, a discussion of the symptom-
atology seems to be most practical from the thera-
peutic standpoint.

Urinary incontinence. During the acute spinal-
shock stage, with complete motor and sensory
paralysis of the bladder, “overflow incontinence”
occurs. In the recovery stage, however, urinary in-
continence is caused by uninhibited reflex con-
tractions of the detrusor due to loss of cerebral in-
hibition and coordination (“active incontinence”)

Vol. LII, No. 2

Journal of Iowa Medical Society

Figure 4. Urinary continence devices: A. Shower cap filled
with waste cotton. B. Condom catheter connected by rubber
tubing to bedside drainage bottle with sterile top. C. External
rubber urinal that fits over the penis, with rubber leg bag
to collect urine.

and not by paralysis of the sphincters (“passive
incontinence”) .

If the uninhibited reflex contractions are spaced
more than an hour apart and are sufficient to
empty the bladder (automatic reflex bladder),
some patients may anticipate them and initiate
urination by straining, and thus stay relatively
dry. The majority of complete and some incom-
plete cord-lesion patients will require an external
continence device (condom catheter or rubber
urinal) (Figure 4). The advantages of using such
a device rather than permanent urethral or
suprapubic catheter drainage are:

1. Foreign-body irritation, incidental to the use
of a catheter, can be avoided

2. The incidences of urinary-tract infections and
stone formation are reduced

3. The patients are always glad to get rid of in-
dwelling catheters and can manage the external
devices more easily and more satisfactorily. Dur-
ing the night, they either put the metal urinal be-
tween their thighs or use a shower-cap arrange-
ment (i.e., sleep in a prone position, with the penis
in a waste-cotton-filled plastic shower cap) (Fig-
ure 4) .

“Urgency incontinence” is a milder form of in-
continence. It may be caused by cystitis, with in-
creased vesical irritability, and may disappear
after the infection has been eliminated. In other
instances, such as incomplete spinal-cord lesions,
it is caused by only partial interference with cer-
ebral inhibition. These patients feel a sudden
urge to void every few hours, and are unable to
postpone micturition until they can reach a suit-
able place to urinate. Bladder sedatives and para-
sympathicolytics such as banthine, 50 mg. q.i.d.,
may be beneficial. Sometimes, also, these patients
will have to wear external urinary continence
devices to keep from wetting themselves.

Residual urine. Incomplete vesical emptying in
the patient with spinal-cord injury or disease is
the result of impaired coordination of the expulsive
and retentive forces, with hypertrophy and spas-
ticity of the internal and, at times, of the external
vesical sphincter. The higher the residual urine
and the smaller the vesical capacity, the more in-
efficient the bladder becomes. The majority of
complete and many of the incomplete lesion pa-
tients carry varying amounts of residual urine,
determinations of which should be done at inter-
vals, since false values may be obtained and since
the residual gradually decreases as the bladder re-
covers. Transurethral resection of the vesical neck
and prostate, and in rarer instances of the external
sphincter, and/or the various nerve blocks and
resections (pudendal, sacral) will eliminate resid-
ual-urine accumulation in most patients. These
surgical procedures, however, should be postponed
until no further recovery of bladder function is
expected.

Initiation of urination by abdominal straining.
In low spinal-cord lesions which destroy the sacral
micturition center at S2-4, there should be no auto-
matic reflex activity of the detrusor, and thus no
“active incontinence” from uninhibited detrusor
contractions. These patients may be able to strain
and expel urine by contractions of their normally-
innervated abdominal muscles (lesion below the
motor horns) supported by manual abdominal
pressure (Crede). Most of them have substantial
amounts of residual urine because of hypertrophy
and spasticity of the internal vesical neck, but this
is amenable to treatment by transurethral resec-
tion. In a satisfactory case of this sort, the patient
will stay dry and can initiate urination by ab-
dominal straining every three to six hours.

In this group, there are occasional patients who
can initiate urination in this way, even though
their spinal-cord lesions are above the sacral
micturition center. Such cases are theoretically
inexplicable.

Complete urinary retention. This group includes
only about five per cent of cord bladders. The com-
plete retention is due to marked spasticity of the
external or, rarely, of the internal vesical sphinc-
ter. Treatment is discussed below, in case report
No. 10 (W. P.).

Ureteral reflux. This results from incompetency
of the normal uretero-vesical valve mechanism.
When one does a retrograde cystogram, the in-
jected contrast medium will fill not only the
bladder but also the ureter and the collecting sys-
tem of the respective kidney.

The incidence of clinically significant ureteral
reflux in neurogenic bladders is between five and
15 per cent. The difficulty is caused by several
factors such as urinary infection, vesical spastic-
ity, deformity and hypertrophy. At the time of
the initial urological work-up, and at intervals
later on, retrograde cystograms are done to de-

Journal of Iowa Medical Society

Febi’uary, 1962

termine the competency of the uretero-vesical
valve mechanism. Patients with complete ureteral
reflux tend to have repeated urinary-tract infec-
tions and progressive destruction of the affected
kidney by hydronephrosis and pyelonephritis.
Milder cases of ureteral reflux may be treated by
catheter drainage, antibiotics and elimination of
the vesical-neck obstruction and residual urine by
transurethral resection. In the more severe and
persistent cases, a “tunnel and cuff ureteroplasty”
combined with a V-Y vesical-neck plasty may be
necessary to restore the competency of the uretero-
vesical valve mechanism and at the same time to
remove the vesical-neck obstruction.

Figure 5A shows the normal anatomy of the
uretero-vesical junction. When the bladder be-
comes filled, the urine volume compresses the por-
tion of the intramural ureter that runs almost
parallel to the trigon. In Figure 5B, the valve
mechanism has been abolished (ureteral reflux),
and the ureter courses in an almost straight line
through the wall of the bladder. It is also frequent-
ly dilated (golf -hole appearance at cystoscopy).
The surgical correction and restoration of this
valve mechanism is shown in Figure 5C. The retro-
grade cystogram of case No. 4 (C. O.), reproduced
in Figure 6, shov/s marked bladder deformity and
hypertrophy on the left side, with complete ureteral
reflux on the same side but none on the side with
normal bladder contour.

FOLLOW-UP EXAMINATIONS

After optimal bladder function has been ac-
complished, the patients are followed up urologi-
eally for the rest of their lives. During the first
five years, intravenous pyelograms and retrograde
cystograms are done every year to discover any
deterioration in renal function or any complica-
tions. The vicious circle of urological complications
is illustrated in the following diagram:

Stasis^- ^Stones

If complications are present, urological check-ups
are done more frequently. Even if bladder and
kidney function have been stable over a period of
five years, the patient should continue to have
urinalyses and intravenous pyelograms every two
or three years.

In from 10 to 20 per cent of patients, all efforts
to make them catheter-free remain unsuccessful,
chiefly because of persistent residual urine,
ureteral reflux or urinary infections.

Figure 5. A. Normal anatomy of uretero-vesical junction,
and course of ureter through bladder wall. Note length
(x — x) of intramural portion of ureter through bladder muscle,
which is chiefly responsible for competence of the uretero-
vesical valve mechanism. B. Neurogenic bladder with de-
formity and spasticity of detrusor muscle deranging the
normal anatomy as depicted in A. In addition, the lower
ureter is dilated, and the ureteral orifice is patulous and
gaping. The intramural portion of the ureter (x — x) is consid-
erably shortened. The result is ureteral reflux. C. Correction
of the condition shown in B, by means of a "tunnel-and-cuff
ureteroplasty." Note the reestablished length of the intra-
mural portion of ureter through the submucosal tunnel (x — x).

Patients with permanent urethral or suprapubic
catheters should be examined more often, and
proper catheter care is of utmost importance, since
such individuals have a greater than normal tend-
ency to develop renal complications and insuffi-
ciency. Case report No. 12 (C. S.) is a good exam-
ple of how a well-rehabilitated paraplegic in a good
professional position has developed severe uro-
logical complications, with precarious renal re-
serve, 14 years after his initial cord injury. The
complications probably could have been prevented
by urological follow-up.

Most female patients whose urinary incontinence
cannot be controlled wear permanent urethral
catheters, since external urinary-continence de-
vices presently available have not proved alto-
gether satisfactory.

In the final section of this paper, case reports
will be presented to demonstrate some of the di-
verse problems encountered in the management of
patients with neurogenic bladders that resulted
from spinal-cord injury or disease.

CASE REPORTS

Case No. 1. L. H., 21 years of age, was admitted
to I.M.H. on October 6, 1960. On June 18, 1960, an
automobile accident had produced a compression
fracture of his Dll xertebra, with resultant spas-
tic paraparesis (incomplete spinal-cord lesion).
His abdominal muscles were intact and of good
contractility. The patient was on urethral catheter
drainage for a period of four weeks following the
injury. The catheter was then removed, and he was
able to void large amounts of urine by abdominal
straining every eight to 12 hours, with less than
100 cc. of residual urine. In between his voidings,
he was continent. The B.U.N. was 12 mg. per cent,
and an intravenous pyelogram showed normal up-
per urinary tracts and a large, smooth bladder. A
retrograde cystogram showed no ureteral reflux.

On November 9, 1960, a retrograde cystometro-

Vol. LII, No. 2

Journal of Iowa Medical Society

gram showed a hypotonic bladder with a capacity
of over 800 cc. There were no uninhibited detrusor
contractions and only 50 cc. of residual urine. At
a bladder filling of 800 cc., the patient was able to
raise the intravesical pressure, by abdominal
straining, to 50 mm. Hg and to expel the fluid in
a slow stream. A Foley urethral catheter was left
indwelling to prevent further bladder distention,
and a repeat cystometrogram was done on Decem-
ber 21, 1960. At that time, the bladder tone was
better, and at a filling of 200 cc. he was able to
raise the intravesical pressure to 110 mm. Hg by
abdominal straining. There was only 10 cc. of resid-
ual urine. After removal of the Foley catheter, he
was able to void by straining every four to five
hours, and to stay completely continent.

This case represents excellent recovery of
bladder function, with abdominal straining, after
an incomplete cord injury. Since the patient also
showed good return of muscle strength in the legs
(although they were very spastic), he was able to
ambulate with the help of a cane, after a period of
rehabilitation. He used a short leg brace on the
right. He was discharged on January 7, 1961.

Case No. 2. W. B., 33 years of age, was admitted
to I.M.H. on March 14, 1961. On January 17, 1961,
he had suffered a fracture dislocation of D 12,/L 1,
with complete paraplegia, when he was hit by a
falling piece of timber. He had previously been on
catheter drainage, but on admission he was with-
out catheter. Since he had good abdominal muscle
contractions, he was able to void by means of ab-
dominal straining. The B.U.N. was 13 mg. per cent,
and an intravenous pyelogram showed normal
upper urinary tracts. No ureteral reflux could be
demonstrated by retrograde cystogram, but some
bladder stones were present, and they were re-
moved transurethrally on March 18, 1961.

On March 25, 1961, a cystometrogram showed
normal bladder tone, and absence of uninhibited
contractions. The patient was able to raise his in-
travesical pressure by abdominal straining to
60 mm. Hg at a bladder filling of 250 cc., and to
120 mm. Hg at a filling of 400 cc. There was less
than 30 cc. of residual urine. The catheter was re-
moved, and the patient was able to void between
300 and 500 cc. of urine every five to six hours and
to stay dry meanwhile.

This is another example of early and excellent
bladder recovery, with urinary continence and
voiding by abdominal straining. The patient be-
came ambulatory, with bilateral long leg braces
and crutches, and was discharged on May 5, 1961.

Case No. 3. J. D., age 18, had suffered a spinal-
cord injury from a gunshot wound at the level of
D8, with complete paraplegia, in November, 1959.
Only his upper abdominal muscles were intact. He
was brought first to one of the Des Moines hos-
pitals, and in January, 1960, was transferred else-
where, where a vesico-cutaneous fistula was done
to drain the paralyzed bladder. That arrangement
broke down, and when we first saw him at Broad-

lawns Polk County Hospital, in Des Moines, we
converted it into a suprapubic cystostomy to keep
the patient dry. An intravenous pyelogram showed
normal upper urinary tracts, and the B.U.N. was
12 mg. per cent.

On October 24, 1960, he was admitted to the
Younker Memorial Rehabilitation Center of I.M.H.
for further urological investigations and rehabilita-
tion. On the next day, a retrograde cystogram out-
lined marked ureteral reflux on the left, and
bladder stones. The bladder calculi were removed
transurethrally, and the urinary-tract infection was
treated until his urine showed only occasional pus
cells per high-power field and mild bacteriuria.
The suprapubic tube was removed and replaced by
a urethral catheter. Cystometrography showed good
detrusor contractions at fillings from 200 to 400 cc.,
but the bladder was hypertonic, and there were
several uninhibited detrusor contractions. The
retrograde cystogram was repeated on December
19, and the left ureteral reflux could no longer be
demonstrated. The urethral catheter was removed,
and the patient voided at irregular intervals. The
residual urine averaged 50 cc. Because of the un-
inhibited contractions and the complete loss of
bladder sensation, he was unable to anticipate the
imminence of urination, and had to wear an ex-
ternal continence device (rubber urinal). Follow-
up examinations since then have shown no changes
in the intravenous pyelograms, and he has con-
tinued to empty his bladder fairly well (less than
60 cc. of residual urine).

This case is an example of automatic reflex
bladder with incontinence. The patient demon-
strated a flaccid type of paraplegia. He learned to
ambulate independently with long leg braces and
crutches, but spent most of his time in a wheel
chair, in which he was independent. He was dis-
charged on December 23, 1960.

Case No. 4. C. O., age 36, had fallen from a
bridge and fractured D 12, with complete para-
plegia, on August 20, 1959. A Foley urethral cathe-
ter had been inserted shortly afterward for con-
tinuous drainage. An intravenous pyelogram at
that time had been negative.

He was admitted to Y.M.R.C. on September 22,
1959, and on October 20, 1959, bladder calculi were
removed transurethrally.

On March 3, 1960, the urethral catheter was re-
moved, and the patient voided 200-250 cc. of urine
at irregular intervals, chiefly by uninhibited reflex
contractions of the detrusor. He had varying
amounts of residual urine (50 to 150 cc.), but be-
cause of his good bladder capacity he was sent
home without an indwelling urethral catheter. He
had to wear a rubber urinal because of urinary
incontinence, but he was ambulatory with bilateral
long leg braces and crutches.

From April 27 to May 1, 1961, he was back in the
hospital for a check up. An intravenous pyelogram
again showed normal upper urinary tracts, and
the B.U.N. was 14 mg. per cent. However, the

Journal of Iowa Medical Society

February, 1962

Figure 6. (Case No. 4, C. O.) Retrograde cystogram with
deformity and pseudodiverticulum on left side of bladder, and
left ureteral reflux outlining left pyeloureterogram.

retrograde cystogram showed marked ureteral re-
flux on the left, with deformity of the bladder on
the same side (Figure 6). Cystoscopy revealed a
very trabeculated, hypertonic bladder, and the
bladder neck appeared obstructive, but there was
only between 50 and 60 cc. of residual urine. There
were uninhibited detrusor contractions, complete
sensory paralysis and hypertonus on cystometric
examinations.

This patient was to be rechecked after another
six months of intermittent chemotherapy. A trans-
urethral resection might not only eliminate the
retention of urine but also abolish the ureteral
reflux.

Case No. 5. J. M., 21 years of age, had suffered
fractures of C6 and D12 in an automobile accident
on April 13, 1960, resulting in a complete para-
plegia and weakness of the left hand. He had also
suffered a crushing injury to the right kidney that
had necessitated a right nephrectomy elsewhere on
June 12, 1960. He had been on continuous ure-
thral-catheter drainage until August 10. He voided
by uninhibited detrusor contractions at irregular
intervals, requiring the use of a rubber urinal. The
residual urine was between 60 and 100 cc.

He was admitted to I.M.H. on September 25,
1960. At that time his B.U.N. was 19 mg. per cent,
and an intravenous pyelogram showed a normal
outline of the collecting system of the solitary left
kidney. The residual urine was 70 cc. A retrograde
cystogram showed reflux along the right ureteral

stump and a deformed bladder (Figure 7A). There
was minimal reflux on the left. A cystometrogram
showed increased bladder tone, a capacity of 100
to 150 cc., and uninhibited detrusor contractions.
There was sensory paralysis. Because of urinary
incontinence, the patient had to continue wearing
a rubber urinal.

On January 12, he developed a boil on the right
buttock, which grew Staphylococcus aureus. On
February 2, he started to have continuous spiking
fever up to 104 °F, associated with severe chills. A
urine culture also grew Staphylococcus aureus.
Another intravenous pyelogram showed no stasis
or deformity of the left renal collecting system.
The lower two thirds of the left ureter was not
outlined by the contrast medium. His staphy-
lococcal infection was treated with erythromycin
and then with albamycin, to which his staphy-
lococci had been sensitive in vitro. The high fever
and chills persisted. Vancomycin, 500 mg. in a
saline infusion intravenously every six hours, was
tried for three days without breaking the fever
and chills.

On February 17, 1961, a cystoscopy and left
retrograde ureteral catheterization were attempted
in order to rule out ony stasis-producing' obstruc-
tive lesion. Also, films were taken during inspira-
tion and expiration on the chance that they might

Figure 7A. (Case No. 5, J. L. M.) Retrograde cystogram
showing reflux into right ureteral stump, and marked deform-
ity of bladder. The patient had had a previous right nephrec-
tomy. There is mild reflux also on the left.

Vol. LII, No. 2

Journal of Iowa Medical Society

reveal a perinephric abscess. The ureteral catheter
hit an obstruction about 3 cm. above the left vesi-
co-ureteral junction, and Figure 7B demonstrates
the narrowing and dilation and the deformity
cephalad of the left ureter. This last no doubt had
been caused by the tremendous hypertrophy and
deformity of the patient’s neurogenic bladder. The
edema caused by his staphylococcal infection had
no doubt further contributed to the obstruction of
the lower left ureter.

On February 18, 1961, a left ureterostomy in situ
was done, and the patient made an uneventful re-
covery. After proper drainage of his solitary left
kidney had been provided, his fever and chills
subsided within two days postoperatively, and
within another week his temperature was down
to normal levels. During the ensuing six weeks,
he was continued on appropriate antibiotics, as
determined by sensitivity studies. The Staphylo-
coccus aureus disappeared from his urine five days
after surgery. Cultures showed mixed infection by
the common urinary pathogens such as Proteus,
coliform organisms and Pseudomonas, but the re-
sult was only a mild pyuria, rather than renal or
systemic infection.

On March 28, 1961, contrast medium was injected

Figure 7B. (Case No. 5, J. L. M.) Left retrograde uretero-
gram showing tip of ureteral catheter 3 cm. above left
uretero-vesical junction and obstructed by a kink in the
ureter due to bladder deformity. Most of the left ureter is
kinked and dilated.

Figure 8A. (Case No. 6, J. H.) Intravenous pyelogram show-
ing three calculi in tips of upper, middle and lower calyces of
left kidney. A fair sized calculus is in the lower left ureter,
without hydronephrosis above it.

through the T-tube into the left ureter, and its
passage down the ureter was observed under cine-
fluoroscopy (image intensifier) . Following the sub-
sidence of the infection and the ureteral edema,
apparently the kinked ureter was again sufficiently
patent to allow the medium to flow down smoothly
into the bladder. The dilation of the lower ureter
had also disappeared. The ureterostomy catheter
was removed, and there was urinary drainage
from its site for only a few days.

The patient’s temperature stayed within normal
limits until his discharge, on May 6, 1961. He had
resumed his rehabilitation program, and on dis-
charge was ambulatory independently, with bi-
lateral long leg braces and crutches. His urethral
catheter was removed and he emptied his bladder
well, but he continued to require a rubber urinal
because of incontinence (automatic reflex bladder) .

In July, 1961, his B.U.N. and intravenous pyelo-
gram were normal.

Case No. 6. J. H., age 65, had fallen from a scaf-
folding on October 12, 1955, suffering a fracture of
C4 and C5, and had become quadriparetic. In Feb-
ruary, 1959, bladder stones had been removed
suprapubically, and a permanent suprapubic
catheter had been left indwelling. These pro-
cedures had been done at another hospital. The

Journal of Iowa Medical Society

February, 1962

Figure 8B. (C asc No. 6, J. H.) Retrograde ureteral catheter
by-passing obstructing left ureteral stone, which has dropped
down from left kidney.

patient was admitted to Y.M.R.C. on January 8,
1961. He had been taking broad spectrum anti-
biotics continuously “to keep from having fever
and cloudy urine.” No recent urological work-up
had been done. The urine was found to be loaded
with pus cells, the B.U.N. was 16 mg. per cent,
and an intravenous pyelogram revealed three cal-
culi in calyces of the left kidney and a large left
ureteral calculus (Figure 8A).

On January 19, 1961, a cystoscopy showed tra-
beculation of grade III and diffuse cystitis. When
a urethral catheter was introduced on the left side
it met an obstruction at the calculus just men-
tioned. While the calculus was being bypassed,
purulent urine exuded from the left ureteral ori-
fice. Prior to the cystoscopy, the patient had had
a fever spiking up to 103 °F.

On January 27, 1961, the left ureteral calculus
was removed by ureterolithotomy. The fever sub-
sided within a few days and his urine became
clear. Since he was quadriparetic and had had a
suprapubic catheter for several years, no attempt
was made to free him from catheter drainage.

He was seen for a check-up six months later.
His urine continued to be clear, in spite of his not
having taken any antibiotics. He was irrigating
his suprapubic catheter with 10 per cent renacidin
twice weekly, and had had it changed every six

weeks. The stones in the left kidney were of the
same size as they had been, and since they were
not causing stasis or obstruction, there was no
indication for removing them. He was discharged
on April 1, 1961, still in a wheel chair, but im-
proved on certain hand and self-care activities.

On October 24, 1961, he developed fever, chills
and left-flank pain. An intravenous pyelogram
showed that one of the kidney stones had descend-
ed into the upper left ureter, and was obstructing
it, causing hydronephrosis (Figure 8B). Cystos-
copy was done, and a ureteral catheter was
passed by the obstructing ureteral stone into the
left renal pelvis, to relieve the hydronephrosis.
After the fever had subsided, the obstructing
ureteral stone and the stones remaining in the left
kidney were removed through a combined pelvio-
nephro-lithotomy. A nephrostomy tube was left
indwelling for a few weeks, and the left kidney
was irrigated with five per cent renacidin solution.
Following removal of the nephrostomy tube, there
was no leakage from the flank, and the patient has
done well since then. A follow-up kidney, ureter
and bladder examination showed no residual stones
in the left kidney. Biopsy of the left kidney at the
time of surgery had shown advanced chronic pye-
lonephritis, but the kidney averaged on output of
800 cc. through the nephrostomy tube (Figure
8B) .

Case No. 7. A. L. P., age 56, had apparently been
in good health, but had started developing gradual
paraplegia on about August 15, 1960. On August
30, he had developed urinary retention, necessi-
tating urethral-catheter drainage. Myelograms had
been done here and at a large clinic, but had pro-
duced no positive findings. A diagnosis of occlu-
sion (thrombosis) of the anterior spinal artery
was decided upon. The blood pressure was 130/80
mm. Hg.

On August 31, 1960, anticoagulant therapy was
started. By then, complete paraplegia had devel-
oped, with a sensory level of D8 to D9. The pa-
tient was admitted to I.M.H. on September 16,
1960. An intravenous pyelogram on October 6,
1960, was negative.

On October 17, 1960, he developed spiking fever
to 104°F., chills and marked pyuria. Another intra-
venous pyelogram on October 22, 1960, showed
delayed function of the right kidney and marked
hydronephrosis. No opaque calculus could be seen.

On October 22, 1960, a cystoscopy was done,
and the right ureter was catheterized, but an im-
passable obstruction was encountered. Contrast
medium outlined a negative filling defect at the
tip of the ureteral catheter (Figure 9A). When the
ureteral catheter was forced somewhat, the tip
could be passed just beyond the negative filling de-
fect, presumably a non-opaque calculus, and a brisk
urinary drip from the hydronephrotic kidney was
obtained. Another ureteral catheter was put up
to the upper ureter, and a five per cent renacidin

Vol. LII, No. 2

Journal of Iowa Medical Society

Murphy drip was started through one of the ure-
teral catheters and was continued for two days.
The patient’s temperature subsided. Antibiotics,
chosen in accordance with sensitivity studies, had
been given for about 10 days, or since the onset
of fever.

On October 24, 1960, the ureteral catheters were
withdrawn, and contrast medium was injected
through one of the catheters when it was at the
level of the ischial spine. The right retrograde
pyeloureterogram (Figure 9B) outlined a normal-
appearing upper urinary tract. The previously seen
hydronephrosis and non-opaque calculus had dis-
appeared. The B.U.N., a few days later, was 11
mg. per cent.

Another intravenous pyelogram was done on
November 7, 1960, and it showed no dilation or
deformity. A retrograde cystogram was negative,
and there was no ureteral reflux.

During December, 1960, the patient developed
convulsions and a pneumoencephalogram sug-
gested a space-occupying lesion in the left parietal
lobe. A metastatic brain tumor was removed on
January 3, 1961. The pathologists’ report was
metastatic clear-cell carcinoma, probably from
renal cortical carcinoma. The previous intravenous
pyelograms were reviewed, and on January 12,
1961, a bilateral retrograde pyelogram was done.
It showed no change in the architecture of the
right kidney as compared with the previous films,
but in the left pyelogram a crescentic deformity
could be seen in the middle portion of the kidney

which may have represented the primary carci-
noma (Figure 9C).

The patient died on March 25, 1961, at a con-
valescent home. Unfortunately, no autopsy was
obtained.

Case No. 8. L. G., a woman 22 years of age, had
suffered a compression fracture of DIO and Dll
in a car accident on July 4, 1959, with complete
paraplegia. She had initially been started on con-
tinuous catheter drainage. She was admitted to
Y.M.R.C. on February 20, 1960.

On February 25, 1960, an intravenous pyelogram
showed a pyelonephritic contracted right kidney,
but the left kidney was normal. Cystometrograms
showed a hypertonic bladder, with low capacity
because of uninhibited contractions. The urethral
catheter was removed for a period lasting from
June to August, 1960, but had to be reinserted
because of uninhibited detrusor contractions and
consequent urinary incontinence.

On October 20, 1960, a retrograde cystogram
showed marked left ureteral reflux, with begin-
ning dilation of the left ureter and kidney (Figure
10A). Since the left ureteral reflux did not disap-
pear on catheter drainage, and since no urinary-
tract infection was present, except for a mild
bacteriuria, a surgical correction of the ureteral
reflux was proposed. This seemed further indicated
by the fact that the patient’s left kidney was the
only one functioning satisfactorily. The right kid-
ney had been reduced to one-third of normal size
and function as a result of chronic pyelonephritis.

Figure 9. (Case No. 7, A. L. P.) A. Retrograde pyeloureterogram made on October 22, I960, demonstrating right hydro-
nephrosis with negative filling defect in the upper right ureter, presumably a non-opaque ureteral calculus. B. Right retro-
grade pyeloureterogram made on October 24, I960, showing tip of ureteral catheter in lower ureter. After two days of
renacidin irrigation of right kidney and ureter, the negative filling defect in the upper ureter had disappeared, as had also
the right hydronephrosis. C. Bilateral pyelograms after a metastatic clear-cell carcinoma had been removed from the brain.
The right kidney architecture is unchanged. On the left there is a crescentic deformity in the middle calyceal group, sug-
gestive of tumor.

Journal of Iowa Medical Society

February, 1962

Figure 10. (Case No. 8, L. G.) A. Retrograde cystogram showing marked reflux of left ureter and kidney, with moderate
dilation. The right kidney is reduced to one-third normal size by chronic pyelonephritis. B. Postoperative ureteroplasty
retrograde cystogram (voiding). Note the funnel-shaped vesical neck after V-Y plasty, and the absence of the previous left
ureteral reflux. C. Intravenous pyelogram. Postoperative left "tunnel-and-cuff ureteroplasty." Left kidney and ureter are nor-
mal. On the right side is the pyelonephritic, contracted kidney which was already present in February, I960.

On November 14, 1960, a left “tunnel-and-cuff
ureteroplasty,” combined with a “V-Y vesical neck
plasty,” was done. At surgery, the previous cys-
toscopic findings were confirmed, the vesical neck
appeared tight, and the bladder was trabeculated
to grade III. The postoperative course was un-
eventful.

On December 2, 1960, the B.U.N. was 5 mg. per
cent. An intravenous pyelogram on December 15
showed good function, and normal outline of the
left kidney and ureter (Figure 10C). The ureteral
dilation had disappeared. A retrograde cystogram
on December 17 showed a funnel-shaped vesical

outlet, and neither it nor a voiding cystogram
showed any ureteral reflux (Figure 10B). The pa-
tient tried to do without the urethral catheter, but
was always unable to anticipate urination and
stayed wet. She tolerates the urethral catheter
well, and has shown no changes in the upper tract
since. Her urine has remained clear, and she has
had no clinical signs of urinary-tract infection.

She learned to ambulate with bilateral long
leg braces and crutches, but spent most of her
time in a wheel chair, in which she was independ-
ent.

Case No. 9. J. D., a five-year-old girl, had been

Figure II. (Case No. 9, J. D.) A. Age 4. Intravenous pyelogram showing left hydronephrosis due to left ureteral reflux.
B. Age 5. Retrograde cystogram. Note the dilated and deformed bladder and the marked left ureteral reflux with hydro-
nephrosis. C. Age 5. Postoperative ureteroplasty retrograde cystogram. Left ureteral reflux is no longer present.

Vol. LII, No. 2

Journal of Iowa Medical Society

Figure I I D. Postoperative ureteroplasty intravenous pyelo-
gram. Left kidney and ureter appear normal again.

born with spina bifida. Surgical repair had been
done at the age of three days, and she had learned
to walk, with a waddling gait, at the age of 17
months. She suffered from urinary incontinence,
recurrent urinary-tract infections, and straining
at urination.

An intravenous pyelogram on December 13,
1956, was grossly normal, but another, performed
on November 10, 1959 (Figure 11A), showed
marked left hydronephrosis. A retrograde cysto-
gram demonstrated left ureteral reflux. She was
put on a multiple-voiding regime, with abdominal
straining and intermittent catheter drainage. An-
other retrograde cystogram, made on January 25,
1961, is shown in Figure 11B. The bladder showed
marked enlargement and dilation, and the left
ureteral reflux was more pronounced.

On March 13, 1961, a left “tunnel-and-cuff ure-
teroplasty and vesical neck V-Y plasty” was done.
Except for some postoperative bleeding, which
was controlled by cystoscopic fulguration, the post-
operative course was uneventful.

A retrograde cystogram postoperatively, on May
18, 1961, is reproduced here as Figure 11C. In the
voiding cystogram, there was no ureteral reflux.
Figure 11D shows the postoperative intravenous
pyelogram made on September 16, 1961.

The patient tries to empty her bladder every
three to four hours during the daytime, and her
mother helps her by applying manual abdominal
pressure. Her residual urine, which was previ-

ously between 100 and 120 cc., is now reduced to
between 40 and 50 cc. In between her voidings by
abdominal straining, she stays relatively dry. Her
urine has been microscopically negative, and there
have been no episodes of clinical urinary-tract in-
fection. As she grows older, efforts will be made
to induce a ryhthmic voiding pattern by abdom-
inal straining, and to attain urinary continence.

Case No. 10. W. P., age 29, had been injured on
July 10, 1960, when a truck under which he had
been working fell on him, fracturing D 11 vertebra
and causing complete paraplegia. Continuous ure-
thral catheter drainage had been instituted early.

On September 2, 1960, the patient had developed
a scrotal abscess, and it had become a peno-scrotal
urethro-cutaneous fistula one week later. The
patient’s catheter had not been taped to his abdo-
men to straighten the peno-scrotal curvature.

He was admitted to Y.M.R.C. on September 14,
1960. On September 16, an intravenous pyelogram
was negative. On the next day, a suprapubic cys-
tostomy and drainage of the scrotal abscess were
done. On November 12, a cystometrogram showed
good bladder tone, several uninhibited detrusor
contractions and good detrusor contractions on
abdominal straining. The capacity was over 500 cc.

On January 26, 1961, the peno-scrotal fistula
was closed and the urethral pseudodiverticulum
formation was excised. A cystoscopy on Febru-
ary 21, showed the urethra well healed. The blad-
der was trabeculated. The suprapubic catheter was
removed to let the suprapubic sinus close, and
urethral-catheter drainage was started.

By March 2, the suprapubic sinus had closed,
and an attempt was made at removing the urethral
catheter, but the patient was unable to void at all.
The cystometrogram was the same as before, show-
ing good detrusor contractions.

On May 2, a pudendal block was done (Figure
12B), with relaxation of the external urinary
sphincter and subsequent voiding by the patient.
A transurethral resection of the prostate and
vesical neck was done on May 18, but the patient
was still unable to void. It was felt that there was
hypertrophy and spasticity of the external sphinc-
ter. Since the patient still had erections, pudendal
neurectomy was inadvisable. A retrograde cysto-
gram showed no ureteral reflux. Thus, on July 3,
a transurethral resection of the external sphincter
area was done. After that procedure and after the
removal of the catheter, the patient was able to
void by uninhibited contractions. He has no resid-
ual urine, but of course has to wear a rubber
urinal for incontinence.

He has learned to ambulate with bilateral long
leg braces and crutches, and was discharged on
July 29, 1961. He is an independent walker with
those devices.

Case No. 11. M. M., age 23, had suffered fracture
of D10 vertebra in an automobile accident on
September 9, 1959, with complete paraplegia. Prior
to his admission to Y.M.R.C., he had had intermit-
tent catheterization at the local hospital where he

Journal of Iowa Medical Society

February, 1962

Figure I2A. (Case No. 10, W. P.) Urethro-cystogram
before pudendal block. Posterior urethra in region of external
sphincter is narrow.

received intital care, and had had about a dozen
episodes of fever, chills and cloudy urine, and had
passed about six urinary calculi. He demonstrated
that he could void by abdominal straining, leaving
no more than 50 to 80 cc. of residual urine, but
he could not anticipate uninhibited detrusor con-
tractions, and periodically wet himself.

On April 7, 1961, a urological work-up showed
a B.U.N. of 11 mg. per cent. A urinalysis showed
grade IV pyuria, and intravenous pyelograms
showed the upper tracts normal, but the bladder
full of large stones (Figure 13).

On April 14, a suprapubic vesical lithotomy was
done for the removal of several large stones. It
was noted at surgery that the patient had a very
much hypertrophied bladder.

On May 1, a retrograde cystogram showed left
ureteral reflux. Several residual urine checks
showed less than 40 cc. Pyuria remained grade
I-II. In spite of good abdominal straining, the pa-
tient wet himself frequently because of uninhibited
detrusor contractions. He therefore started wear-
ing a rubber urinal. He was dismissed on inter-
mittent chemotherapy, and was to be checked in
four months to see whether the ureteral reflux
would disappear. He learned to ambulate on
braces and crutches, though he had not done so
previously, and he was discharged ambulatory on
June 25, 1961.

Case No. 12. C. A. S., age 63, had been struck
by a falling tree on October 9, 1948, and had suf-
fered a fracture of L4, with complete paraplegia.
He had been treated at various medical institu-

Figure I2B. (Case No. 10, W. P.) Shortly after pudendal
intracaine block. Posterior urethra shows wide diameter due
to relaxation of external sphincter.

tions, and was catheter-free on his admission to
Y.M.R.C. on March 21, 1961.

He gave a history of recurrent urinary-tract in-
fections over a period of four years, manifested by
fever and marked pyuria. The latest episode had
occurred two weeks prior to his admission, and
had been treated with broad-spectrum antibiotics,
but without clearing the pyuria. He was voiding
by abdominal pressure, and was losing urine in
between times without being aware of it. He ap-
peared to be in good general condition, was men-
tally alert, and was holding a good and responsible
position in his profession. The laboratory data
were as follows: hemoglobin 9.6 Gm. per cent,
white blood cells 11,250/cu. mm., and B.U.N. 8 mg.
per cent. Urinalysis showed grade III pus, and a
culture grew Proteus mirabilis. The blood pressure
was 140/80 mm. Hg.

In spite of his normal B.U.N., an intravenous
pyelogram showed poorly functioning hydrone-
phrotic kidneys. Cystoscopy revealed an open pros-
tatic urethra, but the bladder was heavily trabec-
ulated, with many cellules and generalized defor-
mity. The ureteral orifices were patulous and gap-
ing, and ureteral catheters could be let up only a
few inches. Retrograde ureterograms showed tre-
mendously dilated, kinked ureters. A retrograde
cystogram demonstrated bilateral ureteral reflux,
with grade IV bilateral hydronephrosis and ureter-
ectasis (Figure 14). There was only 50 cc. of resid-
ual urine. Indigocarmine excretion from each

Vol. LII, No. 2

Journal of Iowa Medical Society

Figure 13. (Case No. II, M. M.) K.U.B. Multiple vesical
calculi. Upper tracts on intravenous pyelogram were normal.

ureteral orifice was delayed and of poor concentra-
tion.

This patient offers a good example of how ad-
vanced renal damage can occur insidiously, and
of how it is preventable if yearly urological check-
ups are performed, including intravenous pyelo-
grams and retrograde cystograms. When we first
saw this man, the dilation and fibrosis of the kid-
neys and ureters had become irreversible, and
corrective surgery would have been of no avail.
So as to prevent further hydronephrosis and pye-
lonephritis, chiefly caused by the bilateral ure-
teral reflux, permanent and continuous drainage
was instituted by means of a Foley urethral cath-
eter, and the patient was admonished to have reg-
ular urological follow-up examinations thereafter.

SUMMARY

A brief review has been given of the neuroanat-
omy and physiology of the bladder. The urological
work-up and management of patients with spinal-
cord injury and disease at the Younker Memorial
Rehabilitation Center of Iowa Methodist Hospital,
Des Moines, have been discussed.

Cystometry is an important adjunct in diag-
nosing and in studying the progress of such pa-
tients.

Classification of the various types of neurogenic
bladders is difficult and often rather artificial.
Classical autonomic reflex or autonomic bladders
are less frequent than are the mixed types. We

Figure 14. (Case No. 12, C. A. S.) Retrograde cystogram.
Marked bilateral ureteral reflux resulting in tremendous
ureteral dilation and bilateral hydronephrosis. The patient
had not been followed up urologically after his spinal-cord
injury in 1948.

have therefore preferred to discuss the diagnosis
and management of neurogenic bladders accord-
ing to the most distressing of the symptoms that
such patients present — incontinence, residual ur-
ine, urgency, retention and initiation by abdominal
straining.

The importance of life-long urological follow-
ups of these patients has been stressed.

Twelve of our cases have been presented to il-
lustrate important points in this discussion.

REFERENCES

1. Bors, E.: Neurogenic bladder. Urol. Surv., 7:177-250,
(June) 1957.

2. Bors, E., Comarr, A. E., and Moulton, S. H.: Role of
nerve blocks in management of traumatic cord bladders:
spinal anesthesia, subarachnoid alcohol injections, pudendal
nerve anesthesia and vesical neck anesthesia. J. Urol., 63:-
653-666, (Apr.) 1950.

3. Emmett, J. L.: “Neuromuscular Disease of the Urinary
Tract” In: Campbell, Meredith: Urology, Vol. II, pp. 1255-1283
(Sect. 11 of Ch. I). Philadelphia, W. B. Saunders Co., 1954.

4. Emmett, J. L., and Dunn, J. H.: Transurethral resection
in surgical management of cord bladder. Surg., Gynec. &
Obst, 83:597-612, (Nov.) 1946.

5. Emmett, J. L., Daut, R. V., and Dunn, J. H.: Role of
external urethral sphincter in normal bladder and cord
bladder. J. Urol., 59:439-454, (Mar.) 1948.

6. Hutch, J. A.: Vesico-ureteral reflux in paraplegic: cause
and correction. J. Urol., 6S:457-469. (Aug.) 1952.

7. McGovern, J. H., Marshall, V. F., and Paquin, A. J., Jr.:
Vesico-ureteral regurgitation in children. J. Urol., 83:122-149,
(Feb.) 1960.

8. Nesbit, R. M., and Gordon, W. G.: Management of

urinary bladder in traumatic lesions of spinal cord and
cauda equina. Surg., Gynec. & Obst., 72:328-331, (Feb. No.
2 A ) 1941.

9. Thompson, G. J., Nourse, M. H., and Bumpus, H. C.,
Jr.: Treatment of paraplegic; observations in series of 101
cases. J. Urol., 57:1085-1096, (June) 1947.

Aneurysm of the Splenic Artery

CLARENCE J. MIKELSON, M.D.
Waterloo

A case of aneurysm of the splenic artery will be
presented. It is an uncommon condition. Beaussier1
first described aneurysm of the splenic artery in
1770, and over 300 cases of it have since been re-
ported. Hogler2 made the first preoperative diag-
nosis, and Winckler3 first recognized the condi-
tion during a surgical exploration. Details of the
roentgenographic appearance of a calcified aneu-
rysm like the one in this presentation were de-
scribed by Lindboe.4

Owens and Coffey5 reviewed the subject and
found rather marked morbidity and mortality.
Their investigation revealed the incidence of rup-
ture to have been 46 per cent in reported cases,
most commonly into the peritoneal cavity, and
less often into an adjacent viscus or into the
retroperitoneal space. They found that roentgeno-
graphic evidence of aneurysm of the splenic artery
had been pi'esent in only 15 per cent of the patients
previously reported, but more recent reports0 in-
dicate that the roentgenographic indications of
calcification are the most frequent manifestations
in over 75 per cent of cases. Further, the incidence
of rupture in the total of 61 cases reviewed by
Spittel et al.,7 early in 1961, was only 8.2 per cent
(5 cases). These marked changes that have taken
place during recent years constitute the main
reason for interest in this subject.

CASE REPORT

A white woman 72 years of age complained of
vague abdominal epigastric pain that became se-
vere enough to need medical attention in Decem-
ber, 1958. The distress had been present for six
months, but there had been no nausea or vomiting.

A general examination revealed no mass or
localized tenderness. The blood pressure was
140/80 mm. Hg. Roentgenograms of the chest,
gallbladder and stomach were normal except for
calcification in the splenic artery and a splenic
aneurysm. Laboratory procedures revealed no ab-
normal blood findings.

Surgical treatment consisted of splenectomy and
removal of the splenic artery proximally enough
so that the resected portion included the aneurysm.
A left subcostal incision was used.

The pathologist reported that the aneurysm was
saccular, that it measured 3.0 x 2.2 x 2.2 cm., and

Dr. Mikelson made this presentation at the meeting of the
Iowa Academy of Surgery, in Iowa City, on October 14, 1961.

that it had been due to arteriosclerosis. The wall
of the aneurysm was calcified, as were the athero-
sclerotic portions of attached splenic artery.

The postoperative course was complicated by
mild cystitis. Thus far, there has been no recur-
rence of epigastric distress.

COMMENT

This woman’s case is fairly typical in that
aneurysms of the splenic artery occur three times
more frequently in women than in men, whereas
all other arterial aneurysms occur in men four
or five times more often than in women. This case
is typical also in that 75 per cent appear in pa-
tients beyond 50 years of age.7

Pain was the predominant symptom, and roent-
genography provided the only positive findings.
In a recent series, as I have said, there were only
about 8 per cent ruptures, as compared with 46
per cent in earlier studies. There are numerous
reports of multiple aneurysms of the splenic artery,
most of them having been atherosclerotic in type.
There may be nausea and vomiting, gastrointesti-
nal bleeding, splenomegaly, palpable mass, marked
tenderness before complications of rupture, or the
patients may be asymptomatic.

Congenital aneurysms show a wall of fibrous
tissue, and are much less common than are the
arteriosclerotic ones. The aneurysms are saccular
and may have mural thrombi. Mycotic aneurysm
associated with bacterial endocarditis can occur.
Rupture can take place in the peritoneal cavity,
into the stomach, into the colon or into other ad-
jacent viscera. An arteriovenous fistula has pro-
duced portal hypertension ascitis. Rupture has oc-
curred during the third trimester of pregnancy
and during the early postpartum period.

In the differential diagnosis, splenic artery dis-
ease can be accurately distinguished from calcified
cysts of the spleen, kidney and adrenal gland, as
well as from aneurysms of the left renal artery,
by means of aortography. Carrying out this type
of study will insure accurate diagnosis, localize
the aneurysm and disclose the coexistence of other
visceral aneurysms.

SUMMARY

In summary, aneurysms of the splenic artery
are most common in females over 50 years of
age. The symptoms are minimal during the early
period, but rupture may occur.

The diagnosis is usually made on the basis of the
typical curvilinear shadow of calcification in the
left upper abdomen found on x-ray. Aortography
will demonstrate the lesion.

The treatment is surgical excision of the po-

Vol. LII, No. 2

Journal of Iowa Medical Society

The aneurysm of the splenic artery reported in the accompanying paper.

tentially serious lesion, before the occurrence of
complications.

REFERENCES

1. Beaussier, quoted by Owens and Coffey (See No. 5,
below) .

2. Hogler, F.: Beitrag zur Klinik des Leber und Milzarterien

aneurysmas: (Zugleich ein Beitrag zur systematischen

Auskultation der Bauchgefasse) , Wein z Arch f inn Med.,
1:509-562, 1920.

3. Winckler, V.: Ein Fall von Milzextirpation wegen

Aneurysma der Arteria lienalis. zbl. Chir., 32:257-260, (Mar.
11) 1905.

4. Lindboe, E. F.: Aneurysm of splenic artery diagnosed
by x-rays and operated upon with success. Acta chir scand.,
72:108-114, 1932.

5. Owens, J. C., and Coffey, R. J.: Collective review;
aneurysm of splenic artery, including report of six addi-
tional cases. Int. Abstr. Surg. (Surg., Gynec. & Obst.),
97:313-335, (Oct.) 1953.

6. Culver, G. J., and Pirson, H. S.: Splenic artery

aneurysms; report of 17 cases showing calcification on
plain roentgenograms. Radiology, 68:217-223, (Feb.) 1957.

7. Spittel, J. A., Jr., et al Aneurysm of splenic artery.
J.A.M.A., 175:452-456, (Feb. 11) 1961.

State University of Iowa
College of Medicine

Clinical Pathologic Conference

SUMMARY OF CLINICAL FINDINGS

A 13-year-old white male child was admitted to
the University Hospitals on December 3 with the
complaint of difficulty in breathing for three days.
He had enjoyed good health until 18 months be-
fore his admission. At that time he had complained
of malaise and anorexia, and had had a low grade
fever. His physician detected jaundice, but no
history of contact with a jaundiced person, or of
blood transfusions or injections, could be obtained.
His hemoglobin at that time was 9.8 Gm./lOO ml.,
and his white blood cell count was 11,050/cu. mm.
The serum bilirubin level was 15.6 mg. per cent,
and the sedimentation rate was 40 mm. in one
hour. During the subsequent two weeks, his stools
became clay-colored, and his urine became the
color of tea. He was treated with rest, vitamins,
liver extract shots and a low-fat diet. After two
weeks, his jaundice lessened, but did not disappear
completely. Three months after the onset of his
jaundice, his serum bilirubin was reported to be
12.6 mg. per cent, and five months after onset, it
was reported to be 24.1 mg. per cent. Subsequent-
ly, the jaundice cleared, and the patient was per-
mitted a limited resumption of activity. He con-
tinued to improve, and seemed well, according to
his parents. He received a weekly 5 ml. intra-
venous injection of Intraheptol.

Two weeks prior to his admission, the patient
and the other members of the family had had a
flu-like infection. The patient continued to cough
after his recovery from the acute phase of the
infection. One week prior to admission, he had
cut his finger on a piece of glass, and the wound
had become infected. Five days later, his cough
had become productive, and his parents noted
that he was having respiratory difficulty. His
sputum was tinged with blood. He was seen by
his physician, given intramuscular injections of
penicillin and Terramycin, and transferred im-
mediately to University Hospitals.

Physical examination showed a drowsy, pale
and dyspneic child. There was an infected lacera-
tion on the index finger of the right hand, and
slight pitting edema was noted on the dorsum of
each foot. His respiratory rate was 45 per minute,

and although the lungs were clear to percussion,
crepitant rales were heard over both anterior and
posterior lung fields. The blood pressure was
110/60 mm. Hg, and the pulse was 100. The tem-
perature was 100. 2°F., rectally. There was min-
imal depression of breath sounds. No cardiac ab-
normalities could be detected on physical exam-
ination. The liver edge was palpable tv/o to three
fingerbreadths below the right costal margin. No
nevi were noted on the skin. No localizing or
lateralizing neurologic signs could be detected,
and the patient did not appear icteric at the time
of examination.

Laboratory studies showed a hemoglobin of 8.2
Gm., and a white count of 10,500/cu. mm., with
65 per cent polymorphonuclear neutrophil leuko-
cytes, 2 per cent eosinophils, 1 per cent basophils,
25 per cent lymphocytes and 7 per cent monocytes.
The hematocrit was 21 per cent. The blood urea
nitrogen was 22 mg. per cent, and the creatinine
was 1.2 mg. per cent. The serum C02 was 15
mEq./L., the chloride 107 mEq./L., the potassium
5.0 mEq,/L., and the sodium 138 mEq./L. The
total serum protein was 7.4 Gm. per cent, with an
albumin of 2.0 Gm. per cent and a globulin of
5.4 Gm. per cent. A throat culture showed normal
flora only. No growth was seen on a blood culture.
The swab from the infected wound on the finger
grew Escherichia coli.

A chest x-ray demonstrated an extensive con-
fluent bilateral pneumonia.

The patient was placed in an oxygen tent, and
was treated with intravenous penicillin and
chloramphenicol. For 18 hours after admission, he
was drowsy and continued to be dyspneic. There
were no changes in his physical signs. He then
suddenly died.

SUMMARY OF CLINICAL DISCUSSION

Dr. Robert E. Carter, Pediatrics: I shall ask Mr.
Bauserman to discuss this case on behalf of the
students.

Mr. Steven C. Bauserman, junior ward clerk: We
are presented, first of all, with two episodes of
disease, one 18 months prior to admission, in
which the patient presented a picture of jaundice.
We should first consider the various kinds of

Vol. LII, No. 2

Journal of Iowa Medical Society

jaundice. As regards hemolytic jaundice, we
should have liked to see the results of Coomb’s
and blood-cell fragility tests, but in the absence
of these, we are satisfied with the lack of increased
amounts of urobilinogen in the patient’s stools,
manifested here by the clay color. Tea-colored
urine suggests the presence of bile, whereas in
most hemolytic jaundices we expect to find none.
We rule out hemolytic jaundice on that basis.

Next, we must consider an extrinsic hemolytic
process causing a calcium bilirubinate stone and
producing an obstructive picture of the extra-
hepatic type. However, we regard this as only a
remote possibility, and there is nothing in the
history to suggest it.

When a patient presents with jaundice, three
questions should be asked. First, was he exposed
to persons who were jaundiced? Second, had he
had transfusions or injections? These are answered
in the protocol. The third question would be: Was
he exposed to insecticides, weed killers or other
toxic substances that are known to cause liver
damage? Perhaps at this time we can request an
answer to that question.

Dr. Carter: This youngster came from a rural
environment, but in all of the information that
we have on him, there is no evidence of his hav-
ing been exposed to a specific toxic substance.

Mr. Bauserman: Thank you, Dr. Carter. We
can thus rule out an extrinsic hemolytic process
due to exposure to a toxic substance.

There are two types of obstructive jaundice,
the extrahepatic and the intrahepatic. We think
an extrahepatic one would be very likely to
cause a fluctuating picture in the hyperbilirubi-
nemia that we see. But in reviewing the common
causes of extrahepatic obstruction, we think of
stones in the common duct; we think of carcinoma
of the head of the pancreas; we think of inflam-
mations or infections in the biliary tract. We think
each of these is rather unlikely in view of the
course of this patient’s illness — the fact that he
had a remission, and his age. Of course, biliary
atresia is another factor we should consider in
most instances, but not in a 13-year-old boy.

Now the next class of entities that we think of
is the intrahepatic — the hepatocellular or “medi-
cal” jaundice, and of course, the commonest type
would be infectious hepatitis or serum hepatitis.
Now, the history is negative in regard to these
two components. However, we know that a per-
son with infectious hepatitis isn’t necessarily
jaundiced, and that children are especially sus-
ceptible to this infection, so we’ll come back to
this possibility as being, statistically at least, the
most likely.

We can think also of infectious mononucleosis
as a possibility in this child. However, the course
doesn’t seem to have shown us a picture of mono-
nucleosis. There were no palpable nodes reported.
We wouldn’t expect it to produce jaundice over

a five-month period and then remit for a year
without treatment, even though we realize that
there is no specific treatment for mononucleosis.

We must also consider the possibility of a leu-
kemia, lymphoma or Hodgkin’s disease, but again,
a remission is rather unlikely once the jaundice
has developed, and we have no other manifesta-
tions of diseases of that type.

We have to consider parasitic intrahepatic ob-
struction in our differential diagnosis, and we
should like to know what his eosinophil count was
at this time. In the absence of that information,
however, we still feel that his course wasn’t typi-
cal of E. histolytica or anything of that kind.

We might also rule out toxic hepatogenous
jaundice on the basis of the patient’s history. And,
of course, the toxic hepatitis would have caused
a rather more acute and short-lived course.

We must think also of the less common entities
such as sarcoidosis, amyloidosis, galactosemia and
the glycogen-storage diseases, but again the pic-
ture doesn’t quite fit. There should be other mani-
festations with any of these problems.

The collagen diseases should be given some
thought, especially lupus erythematosus. It is
commoner in girls, granted, but in 1956 McKay
and Cowling, in Australia, reported an entity
called lupoid hepatitis that they thought might
account for many of the cases which had former-
ly been classified as chronic infectious hepatitis.
These cases, they said, hadn’t been due to per-
sistence of the virus, but rather to an autoimmune
reaction due to some change in the antigenicity
of the hepatic cells, themselves, as a result of
the action of the virus. This is an attractive
possibility because many of the symptoms would
be the same. The reason for the designation
“lupoid” is that positive lupus erythematosus cells
were found in several of those cases. The article
that I found reported on only seven cases.

So we come back to our statistically-most-prob-
able entity, chronic infectious hepatitis. Another
possibility is that there may have been two com-
ponents in this patient’s hepatitis. First of all,
would be infectious viral hepatitis contracted at
the beginning of his course of jaundice, or before
the course of frank jaundice, and second would
be serum hepatitis, which could possibly have
been introduced during his injections of Intra-
heptol. This would have been a rather ironic cir-
cumstance, but nonetheless possible.

Thus, we think that this patient’s disease was
an infectious hepatitis, lingering, fluctuating and
causing severe liver damage. We think this ex-
plains his debilitated condition prior to the onset
of his flu infection, and the infection of one of his
fingers by the E. coli organism, which we know
is a rather mild pathogen.

We think that his terminal illness was a viral
pneumonia (interstitial pneumonia, atypical pneu-
monia— whichever you choose to call it), and

Journal of Iowa Medical Society

February, 1962

superimposed on it, perhaps, a gram-negative-rod
type pneumonia, possibly due to E. coli. We rather
expect to learn that this organism was cultured
from the patient’s lungs at autopsy. We feel that
he was debilitated and had severe liver damage.
He had been supported on weekly Intraheptol in-
jections, or the equivalent of about 165 Gm. of
liver extract per 5 ml. injection. We feel that his
anemia is explained on the basis of an inability
on the part of his liver to store the maturation
factors necessary to regulate his erythropoiesis.

Dr. Carter: Answering Mr. Bauserman’s ques-
tion, I can point out that the eosinophil count was
2 per cent on the first blood count performed by
the home town physician.

Dr. Donal Dunphy, Pediatrics: Since many of
the factors have been mentioned, I shan’t discuss
them so exhaustively in terms of possibilities, but
shall deal more in terms of probabilities.

I think that if we see a 13-year-old child who
presents with fever, malaise and jaundice, we
should think first of viral hepatitis. The limited
laboratory data available — a bilirubin of 15.6 mg.
per cent, an elevated sedimentation rate and a
mild degree of anemia — seem to substantiate our
impression of viral hepatitis. However, I would
point out that the same clinical picture could be
produced by an acute hemolytic process. A de-
tailed history would be helpful. One might search
for substances such as Fava beans that might have
produced it. A detailed family history might be
scrutinized for indications of familial spherocy-
tosis. A careful family history can help to de-
termine what additional laboratory studies should
be carried out.

Obstructive lesions are uncommon in children,
and such problems as exist are almost always as-
sociated with hemolytic disease.

Infectious mononucleosis would seem somewhat
unlikely, although at this early stage one would
be hard pressed to exclude this as a serious con-
sideration in the differential diagnosis. At this
point, I think I should be more comfortable if I
had the results of an appraisal of liver function.
What was the home town physician dealing with
when he first saw this boy — a hemolytic type
jaundice? Or was he dealing with an obstructive
type of jaundice? Such things as a cephalin floc-
culation test, or transaminase or alkaline phospha-
tase determinations would have been very help-
ful in deciding whether it was obstructive or non-
obstructive jaundice. Obstructive lesions, as I
have said, are uncommon in children, and such
problems as cholelithiasis are almost always as-
sociated with hemolytic disease. If this were an
obstructive lesion in association with a hemolytic
process, we’d get into the realm of uncommon
problems.

Some of the data seem to contraindicate an acute
hemolytic process. First, this boy’s white count
was around 10,000 or 11,000, and one would expect

that an acute hemolytic process producing this
degree of jaundice would call forth a more violent
response. Second, one would expect to be con-
fronted not only by the characteristic picture,
say, of spherocytosis, but also by a very active
hemopoietic tissue with a rather striking rise in
the reticulocyte count. Thus, these simple pro-
cedures might help one to formulate some idea
as to whether the chance of an acute hemolytic
process should be investigated further. At this
point I’d be inclined, if I had to make a choice, to
look for infectious hepatitis, either serum or viral,
or to look for infectious mononucleosis. A hetero-
phile agglutination might have been very helpful
reasonably early in the disease.

Subsequent events indicated quite clearly that
the process was obstructive. The absence of bile
in the stool and bile in the urine indicates that
the people caring for the child were dealing with
direct bilirubin, and that the jaundice was of an
obstructive type. Statistically, there is no question
that infectious hepatitis is by far the commonest
problem in this age group, and I think the evi-
dence is quite good that they were dealing with
infectious hepatitis.

There are, however, other agents that produce
hepatocellular damage and may result in an ob-
structive type of jaundice. Insecticides have been
mentioned, but they aren’t very common in pedi-
atrics. Perhaps phosphorus in rat poison, or more
commonly carbon tetrachloride, which is by no
means a rare household agent, may produce this.
By and large, however, patients poisoned by these
substances show a more fulminating course and
present much more severe and acute problems.
So on this basis, one conceivably could feel rea-
sonably sure that toxins had been excluded. One
exception is alcohol. Its likelihood as a toxin in
pediatrics is remote, particularly in this country,
but it has been described in Europe, for example,
where alcohols are introduced much earlier, and
we have seen one child who died of advanced al-
coholic cirrhosis at the age of 13. I must say that
the diagnosis wasn’t made until a house officer
who spoke his native language found, during the
third year of the boy’s illness, that the mother
was bringing beer and whiskey to him in the
hospital.

Returning to the patient under discussion to-
day, I must admit that we really don’t know what
happened to the boy. We are told that his jaun-
dice ostensibly cleared. We don’t have any sub-
sequent bilirubin levels, and as you are quite
aware, a patient can well have bilirubin retention
without visible jaundice. Thus this boy may never
have had a completely normal status as far as
bilirubin is concerned, and much less as regards
more direct sorts of evidence of hepatocellular
damage like cephalin flocculation, BSP or trans-
aminase determinations. I gather that these weren’t
done early in the course of the disease, nor were

Vol. LII, No. 2

Journal of Iowa Medical Society

they done as a follow-up to determine the activity
of the disease.

Dr. Carter: The only tests performed were the
ones that are listed in the protocol.

Dr. Dunphy: I think that the other measure-
ments that I have mentioned would have pro-
vided important information, in addition to what
is described as the patient’s “apparent” well being.
There are people who might even raise the ques-
tion, “With so long a hepatitis, was there no role
for steroid therapy?” In this connection, perhaps
the internists might give us the benefit of their
opinions, since the possible utility of steroids in
long unresolved and presumably infectious hepa-
titis is a highly unusual problem in pediatrics.

Now let’s turn our attention to the episode in
which the patient’s entire family seems to have
experienced an acute, “flu-like” respiratory illness.
I think that the evidence is reasonably good that
this child had a super-infection during that period,
in contrast with his condition during the first five
or six days, which is described as having been
fairly benign. There was a superimposition of ad-
ditional symptoms — an increase in the severity
of his cough and a change in the character of his
sputum. The implication that he had sputum
actually for the first time, and that the sputum
was blood-tinged, suggests bacterial infection
superimposed on influenza or on some one of the
other respiratory viral diseases. The agents which
are most likely to be thus superimposed — and here
I disagree with Mr. Bauserman — are not the gram-
negative organisms. In general, they tend to be
the gram-positive ones, to wit, staphylococci, pneu-
mococci and streptococci. Indeed, much of the
mortality in older and debilitated patients can be
laid at the door of these secondary invaders. A
viral disease may well produce a necrotizing type
of pneumonitis, and progress in spite of rather
vigorous antibiotic therapy because it is the pri-
mary agent. I would favor secondary involvement
with bacteria in this case, however, on the grounds
of the time sequence and of the clinical picture
that the child presented.

One other facet that I think should be empha-
sized is that at the time of the child’s admission
he had respiratory distress and some pitting
edema. If these signs were indicative of cardiac
decompensation, digitalization should have been
considered. Yet I don’t think that the evidence
really supports a diagnosis of cardiac decompensa-
tion. I point first to his pulse rate, 100 beats per
minute, which for a child of his age group isn’t
an elevated one. One would expect a much higher
pulse rate with cardiac decompensation, unless
there were some other compromising factors, and
we know of none. In addition, there is no evi-
dence of cardiac disease other than the pitting
edema. I think this can best be explained in terms
of the patient’s low serum protein and his general

status, rather than in terms of cardiac decom-
pensation.

The liver’s being two or three fingerbreadths
below the costal margin leaves me somewhat in
doubt. Since I don’t know whose fingers did the
measuring, I really can’t tell how far down that
was. Certainly one could expect liver enlargement
at that stage, since liver disease is known to have
preexisted. Actually, it would have been surpris-
ing if the liver had been small and not palpable.
But “two fingerbreadths” doesn’t tell me much of
anything. I am not told whether nodules were
felt, and I am not told the character or the con-
sistency of the liver. These are important consid-
erations that the person dealing with the child
noted, assimilated and used in drawing his con-
clusions. But he has left me without the data on
which he worked.

One thing more that remains to be explained is
this child’s death. We don’t know how seriously ill
he was when he presented. We are told that he had
some dyspnea and that he was put into an oxygen
tent. Then 18 hours later he was dead. I’d like to
sum up his couxse this way. I think he had an in-
fectious hepatitis with hepatocellular damage
which, instead of resolving as it commonly does
in pediatrics, went on to cirrhosis of the liver,
with signs of liver decompensation. Unfortunate-
ly, it seems that he experienced an acute viral
respiratory infection which then became super-
infected with a bacteriologic agent, and that his
demise probably can be attributed to severe pul-
monary hemorrhages, which aren’t uncommon
and which would account for his rapid downhill
course. Pathologically, one would expect that
liver disease and pneumonitis would be compli-
cated by hemorrhage, either with or without a
superimposed bacteriologic infection.

Now if these findings are correct, or even if they
aren’t, I think it would have behooved the people
caring for a child with liver disease to consider
his hematologic status seriously, in terms of hem-
orrhage, since his cirrhosis might have progressed
to the development of varices. Though I have no
evidence to support such a suspicion, hemorrhage
from varices may have played a role in his death.
Rather, I do have evidence for a pneumonitis of
a hemorrhagic type. In a patient with long-stand-
ing or reasonably long-standing liver disease, in
whom one knows that the serum proteins are
lowered, one certainly should be anxious to know
the status of the prothrombin, particularly since
hemorrhagic pneumonitis can be a severe and
rather abrupt event. Even without a lowered pro-
thrombin, a patient may have extensive pulmo-
nary hemorrhage as part of his pathologic and
clinical picture, and with a compromise of that
sort, he is in special danger.

There is, perhaps, one remaining possibility.
This child may have had renal disease in associa-
tion with chronic liver disease. I think this chance

Journal of Iowa Medical Society

is extremely remote, and we have no evidence to
substantiate it. We have no urinalysis that would
indicate any renal abnormalities. Dr. Carter has
told me that I have all of the laboratory data I
need. Second, the blood urea nitrogen is slightly
elevated, but I think no more than can be ex-
plained by the general status of the patient at the
time of his hospitalization, so I have no reason to
suspect an associated renal disease.

Lastly, did this patient have liver coma as a
mechanism of his death? Again, I’d like to call
upon the internist, for I really don’t know what
liver coma is. If it means shock, etc., it is con-
ceivable in this case. As you know, the relation-
ship between ammonia levels and liver disease is
highly controversial. Believing in it is somewhat
like believing in ghosts — if you think there are
such things, you see them, but if you aren’t con-
vinced of their existence, you don’t. I have no
specific reason for suspecting liver coma, except
that people with liver disease are very likely to
respond to either hemorrhage or superinfection
with a disproportionate intensity of shock.

My diagnosis is chronic liver disease, with cir-
rhosis and a fulminating infection, and with a
striking degree of hemorrhagic pneumonitis. I’d
favor a gram-positive organism, rather than a
gram-negative one as a secondary invader, if one
is demonstrated.

Dr. Carter: Thank you very much, Dr. Dunphy,
for a most provocative discussion.

I shall clear up two points. First of all, in Iowa,
it would be unthinkable for a 13-year-old boy to
have an alcoholic cirrhosis. Second, the finger-
breadths were those of average residents’ fingers,
but I think your objection to that sort of measure-
ment should be taken to heart by everybody who
measures organ size.

Dr. George R. Zimvierman, Pathology : At nec-
ropsy, the boy was quite thin and was distinctly
jaundiced. His liver was slightly smaller than
normal, and was nodular. The liver cell nodules
were separated by generally broad bands of fibrous
tissue. This feature, in conjunction with the case
history, practically identifies this boy’s cirrhosis
as post-necrotic and, more specifically, post-
hepatitic, for in nutritional cirrhosis the fibrous tis-
sue is usually of lesser quantity and more evenly
dispersed throughout the parenchyma.

Microscopically, these liver cell nodules had no
normal lobular architecture. That is, the usual
relationships of hepatic cords, sinusoids, portal
spaces and central veins had been lost. These
nodules of parenchymal cells, therefore, were re-
generated nodules from a remnant of a liver
lobule that survived the viral infection. During
regeneration, the stromal elements of the liver
that determine the relationships of portal space,
sinusoids and central vein are pushed aside. It
is this stroma, plus some connective tissue which
proliferates in response to parenchymal-cell ne-

February, 1962

crosis, that makes up the broad bands of fibrous
tissue between the liver nodules.

This rearrangement of the normal relationship
between parenchymal cells and their blood supply
subjects the parenchymal cell to hypoxia. In ad-
dition, it has been shown experimentally that ab-
normal vascular shunts develop, altering the vas-
cular supply to the detriment of the parenchymal
cells. The regenerated and surviving liver cells
are then precariously situated in respect to oxy-
gen supply and to essential nutrients. As a result,
presumably, they are also more susceptible to
various injurious agents. As there is more liver-
cell necrosis, there is or may be more compensatory
liver-cell regeneration, more fibrosis, more altera-
tion of the vascular system, and eventually fur-
ther necrosis. Apparently, then, cirrhosis may be-
come self-propagating, regardless of the cause of
the initial liver-cell necrosis. In this case, there
was no anatomic evidence of persistent viral in-
fection in the autopsy sections. Bile-ductile pro-
liferation occurs with the other liver changes in
cirrhosis, apparently as part of an attempt at re-
pair.

The lungs were boggy and deeply red and red-
purple from hemorrhage into the alveoli and from
congestion. They were three times normal weight.
Only a fraction of each lung was aerated. Micro-
scopically, there were two pathologic processes,
a viral type of reaction, and a bronchopneumonia
with acute inflammatory exudates. The former
was manifest as congestion, exudation of edema
fluid and hemorrhage into alveoli, the presence of
mononuclear inflammatory cells in alveolar spaces
and alveolar walls, and the presence of hyaline
membranes lining some alveoli. These findings sug-
gest viral infection, but don’t necessarily indicate
it. Silo-filler’s disease, for example, could produce
the same changes.

A more acute inflammatory process was super-
imposed upon the viral type of pneumonia. This
deduction is based upon the presence of intense
neutrophilic exudate in some lung lobules. The
nature of this bronchopneumonia was not clari-
fied. Cultures of lung grew out only normal flora,
and no organisms could be identified by means of
Gram’s or Giesma stains of lung tissue. The find-
ings were consistent with those of aspiration
pneumonia, but no aspirated food material could
be found. This, however, doesn’t exclude aspira-
tion as a possible cause of the acute broncho-
pneumonia, and the agent responsible for it there-
fore remains unknown. Lung tissue was submitted
to Dr. McKee for viral studies, and he will discuss
that part of the investigation.

In response to the cardiac status, there were
scattered lymphocytes in the interstices of the
myocardium — enough to make one wonder about
the possibility of clinically significant myocarditis.
Sometimes myocarditis is associated with in-
fluenza. However, without cardiac dilation or

Vol. LII, No. 2

Journal of Iowa Medical Society

myocardial hypertrophy, it is unlikely that there
was a significant cardiac disorder.

As incidental findings, there were numerous,
typically tiny, renal hamartomas. These had the
common composition of fibrous tissue and some
renal tubules.

The frequency with which cirrhosis develops
after viral hepatitis is unknown, since no one
knows the incidence of viral hepatitis. There have
been studies, however, designed to discover the
number of cases of cirrhosis thought to be due
to hepatitis. It appears that about a fourth of all
cases of cirrhosis are complications of viral hepa-
titis. If one excludes biliary cirrhosis or obstruc-
tive cirrhosis, somewhere between 60 and 85 per
cent of the remaining cases can be attributed to
hepatitis. In children — again excluding obstruc-
tive cirrhosis — about 80 per cent of cirrhosis cases
are thought to be due to hepatitis. The severity
of the hepatitis has little relationship to the sub-
sequent development of cirrhosis.

The immediate cause of death was confluent
bronchopneumonia, partly viral and partly of un-
known etiology.

Dr. Carter: Thank you very much, Dr. Zimmer-
man.

I believe you said that at autopsy one of the
patient’s lungs contained “normal bacteriologic
flora.” What does that phrase mean?

Figure I. Low magnification of section of liver. Re-
generated nodules of parenchyma, devoid of normal arrange-
ment of portal spaces, sinusoids and central veins. Between
these are broad bands of scar tissue and (not seen) many
proliferating bile ductules.

Dr. Zimmerman: May I pass that question to
you. Dr. McKee?

Dr. Albert P. McKee, Bacteriology : It means the
sum total of organisms that are found in the
saliva which somehow may have come into con-
tact with this particular specimen — such organ-
isms as alpha hemolytic streptococci, a few pneumo-
cocci (not necessarily virulent), some Hemophilus
influenzae, some Neisseria, perhaps catarrhalis
and flava, and the usual hodgepodge. These are
the normal flora that one could find if he cultured
the mouth or throat of anyone in this room. I
abhor nondescript terms like this one, but using
it is much faster than writing out a long list. Enum-
erating the organisms would be worth while
only if one could then be certain as to their sig-
nificance.

The specimen was brought to me because of my
interest in deaths from viral pneumonias. These
patients may die rather abruptly. Several were
brought to my attention during the 1957 epidemic
of Asian influenza. Although I have tried re-
peatedly, using all the tricks I know, I have never
succeeded in isolating a virus from one of them,
this case included. I’m not sure why we fail.

We do go ahead, then, and look for something
else. We try to establish some viral antigen in
the lung, and in this case, as in two others, we

Figure 2. Lung. Most of the alveoli are filled with edema
fluid and blood, and some are lined by hyaline membranes.
Much of the cellular exudate is of mononuclear type. There
are also some neutrophils from an adjacent area of intense
acute bronchopneumonia.

Journal of Iowa Medical Society

February, 1962

have succeeded. We have been able to show (1) no
viable virus, (2) no hemagglutinins and (3) a
complement-fixing antigen of at least one in-
fluenza virus present in this lung in considerable
quantity. In fact, it would be in about the same
quantity as one would find in an infected suscep-
tible animal that had died of a full-blown pneu-
monia from the virus. The human lung had a titer
of complement-fixing' antigen of 1:64, which is a
good titer.

Now, as to the “why” of this, I am not quite cer-
tain, but I think we are inclined to forget one
thing. We tend to think of infections in relation
to only two groups of people: (1) the completely
immune, whom they fail to affect, and (2) the
completely susceptible, in whom they are ful-
minating things. But I must remind you that all
of us have had influenza repeatedly, and thus
none of us, probably, is completely susceptible.
Conversely, each of us is probably partially im-
mune. When the virus seeds itself in the lung, it
finds itself in an area having a degree of resistance
that is somewhere between the completely sus-
ceptible and the completely immune. I am sure
that this circumstance affects the success of the
virologist in getting the virus out, and to some
extent affects the production of viral antigens.

We have an interesting experiment in a model
population that mimics this situation rather mark-
edly. We use 100 mice in a group, and infect them
with strains of Asian influenza at a very high
dilution — say, 10-9 — which will produce an in-
apparent infection — one that you can’t see. We
wait some six weeks and then infect them with
the next larger dose, namely 10-8. Six weeks later
we use 10-7, and after another six weeks we use
10-6. Some viruses isolated during the Asian in-
fluenza epidemic make the mouse population more
and more immune, so that none of the animals
die. Another strain of virus that we isolated dur-
ing the same epidemic invariably kills a certain
percentage of the mice each time we challenge
them. Those that are killed end up with lungs
that look a great deal like the lung of the patient
whom we are discussing.

We can find complement-fixing antigen in the
lungs of those mice, but we can get the virus out
of only about 50 per cent of them. I cannot help
wondering whether an infection may not smolder
in the lung of the semi-immune person, producing
considerable trouble. If one fails to isolate the
virus, one assumes that it isn’t necessarily causing
the infection. I think we should look for the anti-
gen that might occur in these cases each time. It
might well be there, and it might be the cause
behind the pathologic picture. I think, then, that
there are different strains of influenza causing
different end results in different people.

I’d like to make one comment in regard to hepa-
titis. The virus that we have isolated, at least,
has a very firm hold on the red blood cell and

remains attached at 37°C. This mechanism could
cause the host to produce antibodies against its
own red cells — the autoimmunity that Mr. Bauser-
man mentioned. We can reproduce this condition
experimentally, at least with one virus. A consider-
able quantity of antibody can be produced against
these red blood cells. Perhaps this finding will ex-
plain some of the hemolytic phenomena that are
encountered, and it may help to account for some
of the liver damage. I think that this union be-
tween viruses and red cells is interesting, for if
one tries to absorb out a specific antibody from
these infections with the virus only, he has great
difficulty. If one attaches the virus to the red
blood cell first, however, he can then absorb out
the antibody very nicely. Thus, perhaps there is
considerable going on in the blood streams of
these patients that we don’t really understand.

Dr. Carter: Thank you very much, Dr. McKee.

In summary, then, we have a 13-year-old child
who presented a picture of posthepatitic cirrhosis
and succumbed to an acute pneumonitis, presum-
ably of viral origin. The unanswered question re-
lates to additional infectious agents which pos-
sibly played a role in his pneumonitis.

Dr. Dunphy raised a question concerning the
possible use of steroids in the management of a
smoldering hepatitis, and in the few moments
that remain, I wonder whether anyone with ex-
perience in this area cares to comment on that
point.

Dr. Richard D. Eckhardt, Internal Medicine,
V A Hospital: Recalling the microscopic appear-
ance of the patient’s liver, I don’t believe that any
of us thinks that, adrenal steroid hormones could
have benefited him. It is expecting too much to
suppose that these drugs could have improved the
course of someone whose liver was so extensively
scarred and fibrotic. These agents do appear bene-
ficial, on occasion, for patients whose liver disease
is “active,” as evidenced by constitutional symp-
toms, fever, tender hepatomegaly, mild persistent
jaundice, or elevated serum globulin concentra-
tion. For the infrequent patients with chronic
hepatitis who have positive lupus erythematosus
cell preparations, steroids may be of decided value.
This is also true for the forms of persistent and
chronic hepatitis that occur in girls at about the
time of puberty, and in postmenopausal women.
Although these agents don’t usually achieve the
dramatic benefits that we would desire, they may
be of sufficient value to warrant a trial. When em-
ployed, they should be administered in large to
massive doses, at least initially.

I should like also to comment upon “finger-
breadths.” For several years, I insisted that every-
one record liver size in centimeters, but I found
that the resultant reports were even less reliable
than the old ones. Physicians and students seldom
have rulers with them, and a crude measurement

Vol. LII, No. 2

Journal of Iowa Medical Society

in terms of fingerbreadths is more accurate than
a guess in terms of centimeters.

Dr. William B. Bean, Internal Medicine: I’d like
to suggest a compromise. Let’s each of us measure
the widths of his fingers.

SUMMARY OF NECROPSY FINDINGS

At necropsy, there was bilateral, almost con-
fluent bronchopneumonia. Microscopically, most of
the pneumonic areas were characterized by severe
edema, congestion and hemorrhage, the presence
of intra-alveolar hyaline membranes and exuda-
tion of a few mononuclear inflammatory cells.
In other areas, there was a superimposed abun-
dant exudate of neutrophilic leukocytes. The lungs
weighed a total of 1,340 Gm., about three times
the normal weight.

There were jaundice and hepatic cirrhosis. The

liver was coarsely nodular. The parenchymal
nodules were separated by broad bands of fibrous
tissue, in which there were many proliferating
bile ductules.

Death was due to pneumonia.

STUDENTS' DIAGNOSES

1. Chronic infectious hepatitis

2. Virus pneumonia with superimposed bacterial
infection.

DISCUSSANT'S DIAGNOSES

1. Hepatic cirrhosis

2. Hemorrhagic pneumonitis, with superimposed
bacterial infection.

ANATOMIC DIAGNOSES

1. Bronchopneumonia, bilateral

2. Hepatic cirrhosis, postnecrotic.

LEADING CAUSES OF DEATH IN THE U.S.

921,540

DEATHS AT ALL AGES
DEATHS BELOW 65 YEARS

SOURCE: LATEST AVAILABLE FIGURES (1960)
FROM NATIONAL OFFICE OF VITAL STATISTICS

265,260

DISEASES OF HEART CANCER
& BLOOD VESSELS

More will LIVE
the more you GIVE

ACCIDENTS

PNEUMONIA

DIABETES*

*Below 65, suicide deaths total 15,210;
cirrhosis of liver deaths 14,260

HEART FUND

The nation's principal health enemies are diseases of the heart and blood vessels which, as the above chart shows, claim over
921,500 lives each year. Deaths from these causes represent about 54 per cent of the total in the U.S. — more than the com-
bined total of all other diseases and all other causes. The Heart Fund is our No. I defense against these diseases. Give gen-
erously when a Heart Fund volunteer calls at your home on the weekend of Heart Sunday, February 25.

blood pressure approaches normal
more readily, more safely.... simply

(hydroflumethiazides reserpine, protoveratrine A-antihypertensive formulation)

Supplied: Bottles of 60 scored tablets.

References: 1. Fries, E. D.: In Hypertension, ed. by J. H. Moyer, Saunders, Phila., 1959 p. 123.
2. Fries, E. D.: South M. J. 51:1281 (Oct.) 1958. 3. Finnerty, F. A. and Buchholz, J. H.: GP 17:95
(Feb.) 1958. 4. Gill, R. J., et al.: Am. Pract. & Digest Treat. 11:1007 (Dec.) 1960. 5. Brest, A. N.
and Moyer, J. H.: J. South Carolina M. A. 56:171 (May) 1960. 6. Wilkins R. W.: Postgrad. Med.
26:59 (July) 1959. 7. Gifford, R. W., Jr.: Read at the Hahnemann Symp. on Hypertension, Phila.
Dec. 8 to 13, 1958. 8. Fries, E. D., et al.: J. A. M. A. 166:137 (Jan. 11) 1958. 9. Ford, R. V. and
Nickel I, J.: Ant. Med. & Clin. Ther. 6:461, 1959.

all the antihypertensive benefits of thiazide-
rauwolfia therapy plus the specific,
physiologic vasodilation of protoveratrine A

11 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS BY SERIAL ADDITION OF
THE INGREDIENTS IN SALUTENSIN IN A TEST CASE

(Adapted from Spiotta, E. J.: Report to Department of Clinical Investigation, Bristol Laboratories)

SALUTENSIN

(thiazide

mm thiazide protoveratrine A

J. thiazide protoveratrine A reserpine)

A -i ■ ■ i A

3V2 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS USING SALUTENSIN FROM
THE START OF THERAPY IN A “DOUBLE BLIND” CROSSOVER STUDY

Mean Blood Pressures-Systolic (S) and Diastolic (D)

Placebo Followed by Salutensin
(22 patients)

Salutensin Followed by Placebo
(23 patients)

Placebo Salutensin

Before After Before After

Salutensin Placebo

Before After Before After

BRISTOL LABORATORIES/Div. of Bristol-Myers Co., Syracuse, N.Y.

Coming Meetings

Feb. 13-16

Feb. 15-16
Mar. 15

Feb. 3

Feb. 3-6
Feb. 5-6
Feb. 5-6
Feb. 5-7
Feb. 5-8

Feb. 7-9
Feb. 7-10

Feb. 8-10

Feb. 9-10
Feb. 11
Feb. 12-14
Feb. 12-16

Feb. 12-16

Feb. 13-15
Feb. 15-17
Feb. 17
Feb. 17-24
Feb. 17-24

Feb. 19-21
Feb. 19-23

Feb. 19-Mar. 2
Feb. 20-22
Feb. 20-22

Feb. 21-Mar. 1

Feb. 22-24
Feb. 23-24

In State

Refresher Course for the General Practitioner
(S.U.I. College of Medicine and the Iowa
Chapter of the American Academy of Gen-
eral Practice). University Hospitals, Iowa City
Sioux Valley Meeting (Sioux Valley Medical
Association). Sheraton-Martin Hotel, Sioux
City

Lederle Symposium. Sheraton-Martin Hotel,
Sioux City

Out of State

Conference on Office Gynecology and Obstet-
rics. Presbyterian Medical Center, San Fran-
cisco

Congress on Medical Education and Licensure.

Palmer House, Chicago

Cardiac Auscultation. University of Kansas,
Kansas City, Kansas

Electrocardiography Course II. University of
Nebraska College of Medicine, Omaha
American Academy of Allergy. Denver-Hilton
Hotel, Denver

American Academy of Occupational Medicine.
Pittsburgh-Hilton Hotel, Pittsburgh
American College of Radiology Thirty-eighth
Annual Convention. Roosevelt Hotel, New
York City

Symposium on Infertility (New York Univer-
sity Medical Center and the American Soci-
ety for the Study of Sterility). New York City
Dermatology. University of California, San
Francisco

American College of Legal Medicine. Phila-
delphia

Pediatric Neurology. Center for Continuation
Study, University of Minnesota, Minneapolis
Pathologic Physiology of the Blood Dyscrasias
(American College of Physicians). Washing-
ton University School of Medicine, St. Louis
Medical-Surgical Clinical Symposia: Endo-

crinology, Neurology and Neurosurgery: Neu-
rologic Psychiatry, Medical Problems in Sur-
gical Patients, Pulmonary Disease, Gastroen-
terology. University of Kansas, Kansas City,
Kansas

Cardiac Emergencies. Medical College of
Georgia, Augusta

Special Viewpoints in Pediatrics. University
of California, San Francisco
Conference on EENT. Presbyterian Medical
Center, San Francisco

North American Clinical Dermatologic Soci-
ety. Royal Hawaiian Hotel, Honolulu
Second Postgraduate Seminar, International
Medical-Legal Society. Princess Kauilani
Hotel, Honolulu

Radiology and Radioactive Isotopes. Univer-
sity of Kansas, Kansas City, Kansas
Symposia on Challenging Medical Problems
(American College of Physicians). Baylor Uni-
versity College of Medicine, Houston
Surgical Technique. Cook County Graduate
School of Medicine, Chicago
Psychosomatic Medicine. University of Cali-
fornia, Los Angeles

Theory and Application of Psychosomatic
Medicine. University of California, Los An-
geles

Clinical Postgraduate Program (University of
California at Los Angeles in cooperation with
the National Autonomous University of Mex-
ico School of Medicine). Mexico City

American Academy of Forensic Sciences.
Drake Hotel, Chicago

Hearing and Speech Symposium. University
of Kansas School of Medicine, Kansas City,
Kansas

Feb. 24 Lederle Symposium. Westward Hotel, Anchor-

age, Alaska

Feb. 24-25 Endocrinology. University of California, Los
Angeles

Feb. 26-Mar. 2 General Surgery. Cook County Graduate
School of Medicine, Chicago

Feb. 26-Mar. 2 Course for Physicians in General Practice
(University of California). Mount Zion Hos-
pital, San Francisco

Feb. 27-28 The Application of Computers in Cardiovas-
cular Disease (Heart Association of South-
eastern Pennsylvania). Sheraton Hotel, Phil-
adelphia

Mar. 1-3 Conceptual Advances in Immunology and On-

cology, Sixteenth Annual Symposium on Fun-
damental Cancer Research. University of
Texas M. D. Anderson Hospital and Tumor
Institute, Houston

Mar. 2-3 Operable Heart Disease, Fourth Annual Con-

ference. Presbyterian Medical Center, San
Francisco

Mar. 2-3 Proctology. University of California, Los An-

geles

Mar. 2-4 Annual Meeting of the American Society of

Psychosomatic Dentistry and Medicine. Shore-
ham Hotel, Washington, D. C.

Mar. 3 Coronary Arteriosclerosis. Stanford University

School of Medicine, Palo Alto, California

Mar. 3-4 Annual Meeting, New York Society of Inter-

nal Medicine. New York City

Mar. 3-5 American Society of Facial Plastic Surgery.

New Orleans

Mar. 5-7 Anesthesia for Specialists. Center for Con-

tinuation Study, University of Minnesota,
Minneapolis

Mar. 5-7 Pediatrics Symposium. University of Kansas

School of Medicine, Kansas City, Kansas

Mar. 5-9 Gastroenterology (American College of Physi-

cians). University of Michigan Medical School,
Ann Arbor

Mar. 5-9 Surgery of Colon and Rectum. Cook County

Graduate School of Medicine, Chicago

Mar. 6-7 Southwestern Pediatric Society Spring Lecture

Series. Statler Hotel, Los Angeles

Mar. 7-8 Postgraduate Seminar on Diseases of Bone.

University of Missouri Medical Center, Co-
lumbia

Mar. 7-9 Pain Relief in Childbirth. Cook County Grad-

uate School of Medicine, Chicago

Mar. 8-10 Ocular Motility. University of California, San

Francisco

Mar. 10 Child Development (University of California,

San Francisco). Children’s Hospital, San Fran-
cisco

Mar. 12 Spring Hospital Workshop Program (Kansas

City Southwest Clinical Society). Hospitals
of Greater Kansas City

Mar. 12-14 Gallbladder Surgery. Cook County Graduate
School of Medicine, Chicago

Mar. 12-15 Twenty-fifth Annual Meeting of the New
Orleans Graduate Medical Assembly. Roose-
velt Hotel, New Orleans

Mar. 12-16 Selected Subjects in Internal Medicine (Amer-
ican College of Physicians). University of
Chicago Clinics, Chicago

Mar. 12-23 Obstetrics, General and Surgical. Cook County
Graduate School of Medicine, Chicago

Mar. 13-15 Loma Linda University School of Medicine
Alumni Postgraduate Convention. Ambassador
Hotel, Los Angeles

Mar. 14 Lederle Symposium. Lee Jackson Hotel, Win-

chester, Virginia

Mar. 14-18 Diagnostic Radiology. University of California,
San Francisco

Mar. 15-16
Mar. 15-17
Mar. 16-17

Mar. 17

Infectious Diseases. University of Nebraska
College of Medicine, Omaha

Surgery of Hernia. Cook County Graduate
School of Medicine, Chicago

Treatment of Traumatic Injuries. Center for
Continuation Study, University of Minnesota,
Minneapolis

Special Surgery of the Extremities. Presby-
terian Medical Center, San Francisco

(Continued on page 98)

Vol. LII, No. 2

Journal of Iowa Medical Society

The Brighter Side

After days of battling the deep snow and feel-
ing the bitter cold of arctic blasts, one recalls lines
from a poem that all of us loved in our younger
days:

So all night long the storm roared on:

The morning broke without a sun;

In tiny spherule traced with lines
Of Nature’s geometric signs,

In starry flake, and pellicle,

All day the hoary meteor fell;

And, when the second morning shone,

We looked upon a world unknown,

On nothing we could call our own.

Around the glistening wonder bent
The bhie walls of the firmament,

No cloud above, no earth below, —

A universe of sky and snow!

Or one remembers the lines that Robert Frost
was inspired to write after a similar experience:

The way a crow
Shook down on me
The dust of snoio
From a hemlock tree

Has given my heart
A change of mood
And saved some part
Of a day I had rued.

The day’s end, when one’s tasks are done, is a
time to dream of warmer places. Escape to the
Arizona or Florida sun eludes most of us, but with
Emily Dickinson we can indulge in revery:

To make a prairie it takes a clover
and one bee, —

One clover, and a bee,

And revery.

The revery alone will do
If bees are few.

Prophylaxis for Marital Difficulties

In addition to diagnosing and treating diseases,
preventing physical illness, coping with psychoso-
matic complaints and dispensing health advice,
the physician is asked to attempt solving individ-
ual marriage problems. Often, one of his hours is
consumed as a distraught and tearful wife tells
him of her troubles with her spouse. He does his
best to soothe and to counsel, but he needs help
from society as a whole. The high divorce rate in
this country attests to the great frequency of un-
happy marriage.

In a discussion of psychosomatic gynecology and
obstetrics, Marbach,* of the University of Penn-
sylvania, has presented the seriousness of the
problem emphatically: “Preparation of the adoles-
cent girl for a role in life as a wife and mother
is unfortunately the most neglected part of her
education in our society. Emphasis is often placed
on spheres of achievement that have nothing to do
with her being a woman. Frequently all her as-
piration, education and other activities are direct-
ed toward a masculine type of competitiveness
and achievement, inhibiting wholly or partially
her development as a woman. . . . The adolescent
girl who clings to infantile love (to her parents’
delight) will be incapable of entering into satisfac-
tory interpersonal relationships or of adequately
filling her role as wife and mother.”

The developing child’s image of marriage is de-
termined primarily by the example that he or she
observes at home from day to day. Genuine love
and respect are as obvious as integrity and ideal-
ism. No amount of acting or deception will fool the
child.

Physicians who are confronted with the prob-
lems of the unhappy married couple are im-
pressed by the immaturity of either the wife or
the husband or both. Parents are prone to pro-
long a child’s dependency, clasping the youngster
to their bosoms and encouraging the continuation
of his or her infantile love for them. The adoles-
cent must have limits set for him or her, must
have guidance, and must be assured of a lasting
place in the parents’ affection. But the adolescent
must gradually be relinquished to make his or her
own decisions, to develop initiative, to establish
an identity in a larger social sphere, to acquire
self-confidence, and to mature emotionally. Paren-
tal supervision and direction, on the one hand, and
relinquishment, on the other, must be in tenuous
equilibrium from day to day, and it is not easy
for the wisest parent to know when to hold on
and when to let go. Prolongation of dependency
jeopardizes the child’s maturation, but permissive-
ness and the imposition of responsibilities beyond
the adolescent’s capabilities are hazardous.

Undoubtedly there is a part for the schools to
play in this process, but it hasn’t yet been ade-

* Marbach, A. H.: Study of psychosomatic gynecology and
obstetrics, postgrad, med., 30 :479-488, (Nov.) 1961.

Journal of Iowa Medical Society

February, 1962

quately defined. It is questionable whether knowl-
edge of sex and sex technics helps to qualify the
young' man or the young woman for marriage.
Vastly more important as a basis for happy mar-
riage is, as we have said, the privilege of growing
up in a home where he or she subtly becomes
aware of the love and respect that marriage part-
ners should have for one another, and is given an
opportunity to mature without excessive pres-
sures, to acquire wholesome restraint in conse-
quence of wise discipline, and to learn, by exam-
ple and by intimate association, those interper-
sonal relationships which assure a good and happy
adjustment in marriage. Growing up in such a
home, a child learns the basic truth that mature
happiness is the great emotional reward that
comes from giving and serving.

Yet if, as Dr. Marbach so clearly suggests,
preparation of the adolescent girl for her role of
wife and mother is the most neglected part of her
education, then our schools should be called upon
for help. In secondary schools and colleges, young
people should receive formal instruction on the
meaning of marriage and the elements that are
necessary to make it succeed.

In the meantime, the physician can and should
continue playing an important part in assisting
parents and in counseling adolescents, but it would
appear wise for our schools to place less emphasis
on preparing young women to enter business or
professional life, and to make a greater effort to
equip them for their almost inevitable roles as
wives and mothers.

Medical Self-Help Training Course

Dr. Marion E. Alberts, of Des Moines, chairman
of the IMS Committee on National Emergency
Medical Service, attended a conference in Battle
Creek, Michigan, December 3-7, relative to the
Medical Self-Help Training Course that is about
to be set up in communities throughout the coun-
try as a part of the Civil Defense program. In-
struction in considerably augmented first-aid care
is regarded as essential for at least one member
of every household, particularly in the event of
nuclear attack, when family groups, each contain-
ing some injured individuals, are likely to be iso-
lated for a considerable period of time. Dr. Alberts
was in Battle Creek as the IMS representative on
the Governor’s Advisory Committee on Medical
Self-Help, the other members of which are the
state commissioner of health, the state superin-
tendent of public instruction and the state director
of civil defense.

Dr. Alberts reports that of the 5,000 sets of in-
structional materials currently ready for distribu-
tion, 57 sets have been allocated to the State of
Iowa. Additional sets will become available later,

but these first few will be distributed through Dr.
E. G. Zimmerer’s office to public health nurses in
most counties. The nurses will conduct the first of
the classes, in cooperation with local civil defense
directors and the medical committees that have
been set up under the auspices of the Iowa Inter-
professional Association. Each of the latter groups
consists of a physician, a dentist, a veterinarian,
a nurse, a pharmacist and a hospital administrator.
As this is written, the instructional materials
haven’t yet been delivered.

Operational plans will be more specifically
formulated as texts and syllabi become available
in considerable quantities. Members of the IMS
will be kept informed.

The Medical Self-Help Training Program has
been heartily endorsed by the AMA, for if nuclear
radiation were to make it hazardous for anyone
to move from underground, doctors — of all people
— shouldn’t be required to expose themselves by
moving about their communities unnecessarily.
The doctors of Iowa are urged to arouse the pub-
lic’s interest in this program and to help sustain it.

Acne

Physicians and laymen are confronted by a
profusion of available preparations for the treat-
ment of adolescent acne, and exaggerated claims
have been made for many of them. In an endeavor
to end this confusion and to determine the value
of topical therapy as an adjunctive measure in the
treatment of this condition, Robinson* and his
colleagues at the University of Maryland conduct-
ed a study of a large number of patients, using
coded preparations. Since each material employed
had a code number and no one knew, until the
end of the test, which patient received which prod-
uct, their tabulation of objective results and sub-
jective reactions is significant.

The authors have emphasized that therapeutic
measures in cases of acne must be individually
tailored for each patient. The general measures
ordinarily used are very important. Adolescents
need patience, understanding and encouragement.
Good rapport between physician and patient is es-
sential if good results are to be obtained. The diet
should not include chocolate, nuts, fried foods,
butter, pastry, salad dressing or other oily foods,
or highly seasoned foods. The patients included in
the study were instructed to wash thoroughly with
a bland soap every morning and evening. Medica-
tion was to be applied twice daily after the cleans-
ings.

The 12 preparations used in the study consisted
of various concentrations and combinations of sul-

* Robinson, H. M., et al.: Topical acne therapy, south,
m. j„ 54:1105-1110, (Oct.) 1961.

Vol. LII, No. 2

Journal of Iowa Medical Society

fur, resorcin, neomycin and hydrocortisone. The
controls were given the cream base in which the
drugs were incorporated.

Of the patients who received topical therapy, 55
per cent showed some improvement, whereas of
the patients who received only the cream base, 51
per cent improved. Inasmuch as the results of top-
ical therapy were about equal, regardless of the
agent used, and since the placebo apparently had
the same therapeutic efficacy, it was assumed that
any improvement observed could be attributed to
the general measures employed, rather than to any
topical application. The authors said, “In view of
the results obtained in this study with the placebo
preparations, it is probable that local therapy of
acne with preparations containing sulfur, resorcin
or combinations of these may not have the ther-
apeutic value attributed to them in the past. . . .
The incorporation of hydrocortisone in any acne lo-
tion or cream may produce involution of any con-
comitant seborrheic dermatitis, counteract the ir-
ritating effects of sulfur or resorcin, but have no
other beneficial effect on the acne lesion.”

In a separate study by Robinson, patients were
limited to the use of special cleansing pad packets
without any other topical application. Each pack-
age contained 50 packets of cellulose towels im-
pregnated with a solution containing alcohol, an
antiseptic and 0.15 per cent allantoin. After 86 pa-
tients with varying degrees of acne had used this
method of treatment for periods ranging from two
to six weeks, 71 were moderately to markedly im-
proved. From that preliminary study, it was felt
that the method had definite merit, was con-
venient and pleasant, and was highly acceptable to
the patients.

In the management of adolescent acne, it is ob-
vious that dependence upon topical therapy alone
will prove disappointing. The general measures
employed — dietary restrictions, improved hygiene
and encouragement from a wise physician — play a
more important role in producing good results
than does the use of topical applications.

yOU’LL HEAR ABOUT . . .

Medicine's fight to preserve the private
system of medical care
at the

ANNUAL MEETING OF THE IOWA
MEDICAL SOCIETY
May 13-16

Veterans Memorial Auditorium, Des Moines

Smoking Habits

A recent report on a survey of the smoking
habits of high-school students in Newton, Mas-
sachusetts,1 has presented some rather startling
data. In the study it was ascertained that the share
of smokers increased consistently from 4 per cent
in the seventh grade to 50 per cent in the twelfth
grade. By the time the students reached the
twelfth grade, seven in 10 were smokers or dis-
continued smokers, and in that grade 18 per cent
of the boys and 10 per cent of the gii'ls were
smoking five or more packs of cigarettes per
week. More boys than girls smoked in the seventh
to tenth grades; the numbers were equal in the
eleventh grade; and more girls than boys smoked
in the twelfth grade. In all grades, the boys were
heavier smokers than the girls.

Apropos of cigarette smoking by young people,
an article by Ann Mullins2 in lancet has made a
plea for truth in advertising and has deprecated
the fact that vast sums are being spent for tobac-
co advertising directed particularly at young peo-
ple. She has said, “Few medical men doubt that
cigarette smoking is a causal factor in much dis-
ease of the lungs. Deaths from carcinoma of the
lung continue to increase, so nowadays about 52
people die from it every day, compared (for in-
stance) with 16 on the roads. Chronic bronchitis
— a disease which is rare in those who never have
smoked — kills about 30,000 people annually and
disables many more.”

In the British medical journal,3 it has been re-
ported that £20,000,000 is spent annually to ad-
vertise tobacco in the British Isles, and £1,140,-
000,000 was spent for tobacco there in 1960, of
which £1,002,000,000 went for cigarettes. From
the expenditure on tobacco, the British govern-
ment derived a revenue of £826,000,000, which
was more than the cost of the National Health
Service! Mr. Noel-Baker, a member of parliament,
urged that the government undertake a more
serious effort to warn young people of the haz-
ards of smoking, and said that the sums expended
for that purpose “had been no more than a miser-
able trickle.”

The advertising of tobacco has been forbidden
in Sweden since 1956, but surprisingly the con-
sumption of tobacco has not been noticeably re-
duced.

According to statistics published in our daily
newspapers a few weeks ago, Americans spent
$6,900,000,000 for cigarettes last year, setting a new
record. Sixty per cent of the men and 36 per cent
of the women in this country now smoke, and the
numbers of young smokers are still rising. By
every avenue of communication, the public is
assailed by advertisements for tobacco. Sultry-
voiced glamor girls sing of the joys conferred by
Brand X cigarettes. Professional athletes, having
adapted their preferences to suit the highest bid-

Journal of Iowa Medical Society

February, 1962

der, prate of the superiorities of Brand Y, and
first one beauteous young lady and then another
gazes soulfully at a babbling brook, while holding
a cigarette of Brand Z between her dainty out-
stretched fingers. Modern tobacco advertising is
in poor taste, and it invites the gullible to em-
brace a habit that is just as much an addiction
as is the use of alcohol or drugs.

That cigarette smoking contributes nothing to
an individual’s health is unquestioned, and its ill
effects are generally recognized by the medical
profession. If the findings in Newton, Massachu-
setts, are representative of the smoking habits of
the young people in this country, it would appear
fitting that a reasonable share of the immense
income derived from the taxes on cigarettes
should be used by federal and state health agen-
cies to counteract the impact of cigarette adver-
tising. The physical ill effects of smoking and the
likelihood of addiction could be presented with
much greater emotional appeal than the alleged
merits of any “coffin nail.”

REFERENCES

1. Salber, E. J., et al.: Smoking habits of high-school stu-
dents in Newton, Massachusetts. New England J. Med.,
205:969-974, (Nov. 16) 1961.

2. Mullins, A.: Advertisements for health: plea for truth.
Lancet, 2:648-653, (Sept. 16) 1961.

3. Medical Notes in Parliament: Tobacco advertising. Brit.
M. J., 2:1158-1159, (Oct. 28) 1961.

Pulmonary Sarcoidosis

A recent article by Hoyle1 has added significant-
ly to our knowledge of the natural history of
pulmonary sarcoidosis, and has led to a classifica-
tion of the disease into three recognizable types.

Seeing 125 cases of pulmonary sarcoidosis over
periods ranging from two to 22 years provided
Hoyle unusual opportunities to study the condi-
tion. The initial roentgenograms in that group re-
vealed only enlargement of the hilar nodes in 48
patients; pulmonary infiltration and hilar-node en-
largement in 62; only pulmonary infiltration in 9;
and pulmonary fibrosis in 5.

In the group of 48 patients who initially had
only hilar enlargement, seven were eliminated
from the longitudinal study because they were
treated for a complicating uveitis. In two-thirds
of the 41 untreated patients, the enlarged nodes
resolved completely within a mean time of one
year from recognition, and nodal enlargement did
not recur. In four patients, the nodal lesions grad-
ually regressed over several years, but they were
left with recognizable nodes. In the remaining
patients — some 7 per cent — the nodes remained
much enlarged and were thought to be hyalinized.
The patients with only nodal enlargement re-
mained well and were free from symptoms of
functional defects. In one-fifth of the group with

nodal enlargement, pulmonary infiltration de-
veloped, usually within one year and rarely after
two years. Hilar-node involvement was not seen
to occur after pulmonary infiltration, but always
preceded or accompanied it.

In the group of untreated patients who had
pulmonary infiltration, 41 per cent acquired nor-
mal roentgenograms within an average of one
year, though clearing did not occur until two or
three years in some individuals. After the infiltra-
tion had cleared, there were no recurrences. In
about 40 per cent of all patients with infiltration,
the parenchymal lesion remained unchanged, but
in a considerable number there was increasing in-
filtration for a variable period of time. This group
of patients had failed to show lung destruction
from fibrosis, and even after many years they had
not become respiratory invalids. This group of
patients remained well, and were working despite
the persistence of their lesions.

Quite in contrast to the relatively benign
courses of most of the patients with pulmonary
infiltration, in some 19 per cent the course was
one of steady deterioration, with slowly advanc-
ing invalidism from lung failure. Dyspnea was the
main symptom, and became significant after about
five years, at the time when the fibrosis was
recognized roentgenologically. Bronchiectasis and
bronchostenosis developed, and secondary infec-
tion was frequent. This type of progressive sar-
coidosis resulted in cor pulmonale after about 10
years of illness. Half of the patients with pro-
gressive pulmonary sarcoidosis have died, though
the mortality in the whole series of 125 patients
had been no more than 6 per cent at the time of
the report.

From these observations, Hoyle recognizes three
types of pulmonary sarcoidosis: (1) benign with
spontaneous resolution; (2) chronic but nonpro-
gressive; and (3) chronic and progressive. The
outcome depends upon the duration of the active
sarcoid process in the lung. To date, the factors
which control the time the sarcoid process re-
mains active in the lung are completely unknown.
Type 1 can usually be recognized within a year,
and Types 2 and 3 can usually be differentiated
within two years. It is at times difficult to be sure,
even as late as five years after the discovery of
the disease, whether a persistent pulmonary in-
filtration will be progressive and result in severe
fibrosis. The progression from Type 2 to Type 3
is best determined by repeated assessment of pul-
monary function, particularly the diffusing capac-
ity.

The importance of proper classification of pul-
monary sarcoidosis is apparent when it is ap-
preciated that the prognosis and the treatment
may depend upon the type of disease. Patients
whose disease belongs to Type 1 require no treat-
ment, for the course is self-limited. Patients with
Type 2 disease ordinarily have good prognoses,

Vol. LII, No. 2

Journal of Iowa Medical Society

the disease is compatible with good health and an
active life, and the need for corticosteroid therapy
is judged on the basis of the clinical course and
the results of pulmonary-f unction tests. Patients
with conditions in the Type 3 category require
corticosteroid therapy. However, to be effective it
must be continued for many years, since the ac-
tive course of Type 3 sarcoidosis continues for 10
years or more. If steroid therapy is stopped be-
fore the cessation of the active process, relapse
is inevitable and swift.

Shortly after the publication of Hoyle’s study,
Scadding2 reported a very similar experience with
136 patients whom we had observed over a five-
year period. When seen initially, 32 patients had
hilar-node involvement only; 40 patients had hilar
nodes and pulmonary infiltration; 37 patients had
pulmonary infiltration without demonstrable hilar-
node involvement; and 27 patients were judged to
have pulmonary fibrosis when first observed.
After five years of observation, only one patient
who had only hilar-node involvement had appre-
ciable disability. Of the 40 patients with pulmonary
infiltration and hilar-node involvement, only three
had moderately severe symptoms that interfered
with a normal life. Six patients with pulmonary
infiltration only had moderate disability after
five years. During the period of observation, six
of the 27 patients with pulmonary fibrosis died
from sarcoidosis, but when first seen this group
of patients had been ill for an average of 5V2
years. Ten of the patients remained unchanged;
seven showed some improvement; three became
worse; and one patient died from an unrelated
cause.

Concerning corticosteroid therapy of pulmonary
sarcoidosis, Scadding said: “Observation both of
the present series and of subsequent cases of
sarcoidosis has led me to the firm opinion that
corticosteroids have no effect upon the principal
criterion of prognosis adopted in this analysis —
namely, the attainment and maintenance of a nor-
mal chest radiograph with freedom from symp-
toms.” He pointed out that when the manifesta-
tions of the disease are in a reversible stage, they
can be suppressed by administering corticosteroids,
but when therapy is withdrawn, the disease may
return to its former state, may seem to have been
“cured” in that its does not reappear, or may re-
crudesce to a worse state than formerly. Both
Hoyle and Scadding conclude from their expe-
rience that the ultimate outcome of the disease
is not significantly altered by corticosteroid ther-
apy.

REFERENCES

1. Hoyle, C.: Prognosis of pulmonary sarcoidosis. Lancet,
2:611-615, (Sept. 16) 1961.

2. Scadding, J. G.: Prognosis of intrathoracic sarcoidosis in
England; review of 136 cases after five years’ observation.
Brit. M. J., 2:1165-1172, (Nov. 4) 1961.

Cortisone in Kerosene Pneumonia*

Pneumonia has long been known as a major
complication of the ingestion of kerosene and other
petroleum products. Although mild central nerv-
ous system depression is frequently described
as an aftermath of such ingestion,1’ 2 the number
of severe central nervous manifestations (includ-
ing coma and convulsions) is relatively small,
ranging from 3 to 6 per cent.1-3 Pneumonia, on the
other hand, is said to occur in from 30 to 48 per
cent of cases,1-5 and if the number of cases of
pneumonia found is compared to the total num-
ber x-rayed, the percentage is even greater. The
majority of authors3-8 contend, on the basis of clin-
ical observations and experimental results, that
the major hazard of kerosene ingestion is that
of aspirating the material and developing pneu-
monia, but agreement is by no means unanimous.9
Richardson and Pratt-Thomas,6 extrapolating from
experiments with dogs, calculated that more than
a pint of kerosene would be required to kill a 50-
pound child, whereas 5 ml. intratracheally would
cause a severe illness which would probably be
fatal. Since intravenous kerosene has been shown
also to cause a severe pneumonia,8’ 9 especially
when injected rapidly, it is difficult to be certain
about the pathogenesis of this complication in clin-
ical situations, but the weight of evidence at pres-
ent suggests that aspiration is the most important
mechanism causing pneumonia after kerosene in-
gestion. At any rate, pneumonia occurs frequently,
is sometimes serious, and seems to be implicated
often as a direct or indirect cause of death in fatal
cases. The need of an effective treatment for such
pneumonia is thus apparent, and, since the pneu-
monia is presumably the manifestation of an acute
inflammatory response to the presence of kerosene,
attacking the problem by suppression of this
response seems a reasonable approach.

Cortisone has been shown to suppress all ele-
ments of wound healing in certain laboratory ani-
mals,10-13 an effect which included almost com-
plete suppression of the formation of granulation
tissue13 and inhibition of phagocytic activity, as
evidenced by failure of carbon particles to be
transported from the peritoneal cavity to the
regional lymph nodes.12 Cortisone pretreatment
also suppressed chemically-induced inflammation
in mice,14 and treatment with cortisone after chal-
lenge with turpentine tended to have the same
effect, although the effect was not as marked.
These effects were accompanied, however, by
greater extension of necrosis in treated animals
than in controls. Cortisone inhibits the growth of
adult fibroblasts and markedly retards the migra-
tion of white blood cells in vitro.15

In 1952 Nassau16 reported the use of cortisone

* From the National Clearing House for Poison Control
Centers, June, 1961.

Journal of Iowa Medical Society

February, 1962

in the treatment of kerosene pneumonia in three
children. He used a single injection of 50 mg. of
cortisone and obtained impressive clinical re-
sponses in all three patients. In view of the dem-
onstration that various adrenocortical steroid
preparations are capable of inhibiting acetylcho-
line and pilocarpine-induced (and to a lesser ex-
tent histamine-induced) contractions of smooth
muscle from several organs, including the tra-
chea,17 Nassau’s interpretation that the pulmonary
changes following kerosene ingestions are due to
bronchial obstruction and bronchospasm is inter-
esting. He believed that his single injection of cor-
tisone relieved the bronchospasm and allowed the
expectoration of the obstructing liquid.

Graham18 reported impressive clinical responses
on two occasions in a single adult patient in whom
cortisone was first used 14 days after aspiration
of crude oil, after antibiotics had failed to clear
up either the lung reaction or the symptoms of
cough, fever, and respiratory distress. The symp-
toms improved, only to worsen 2 weeks later on
gradual withdrawal of the cortisone. Cortisone,
300 mg./day, was begun again, and again the
symptoms abated, remaining under control for
the nine-month duration of cortisone treatment.
There was not, however, a clear demonstration
that the cortisone favorably affected the lung
changes, as evidenced by the chest x-ray.

Mayock et al.19 recently reported another single
case of kerosene pneumonia treated with adreno-
cortical steroids. This patient had severe symp-
toms, including dyspnea, hemoptysis, and pleuritic
pain, and also had clinical and radiologic evi-
dences of considerable lung involvement. Thirteen
days following ingestion, the inception of predni-
sone treatment was followed by dramatic diminu-
tion of the symptoms and, perhaps, some evidence
of x-ray clearing. Withdrawal of the steroid 9 days
later was accompanied by exacerbation of the
symptoms, but improvement was again obtained
with triamcinolone, although the production of
sputum containing some blood continued. This
patient eventually underwent a right middle lobec-
tomy for bronchiectasis and “lipoid pneumonia.”

Arena20 has used adrenocortical steroids to treat
a few patients who were seriously ill with kero-
sene pneumonia and believes that the results have
been most beneficial. The only controlled series of
patients treated with steroids for this condition
revealed no advantage of treatment with 40
mg./day of prednisone over more conventional
therapy,21 but the objection may be raised that
none of these patients was severely ill, and it is
in serious cases that adrenocortical steroids would
be expected to demonstrate their greatest effect.

The case for using adrenocortical steroids in
kerosene pneumonia receives some support by
analogy with their effect in treating pulmonary
irritation from certain other substances. Holmes22
believes that he has markedly improved the clin-

ical courses of seven patients who were treated
with prednisone or ACTH soon after inhaling
chlorine gas. In another patient a delay of six
hours occurred before treatment was begun, and
this patient had a long and severe hospital course.
There was a general feeling that adrenocortical
steroids benefited a number of patients who had
aspirated gastric contents during anaesthesia;23
pretreatment with prednisone protected guinea
pigs from the effects of the inhalation of chloropi-
crin;24 and prednisone has seemed to allay symp-
toms following nitrogen dioxide inhalation.25’ 26
In general, therefore, there are some indications
that the adrenocortical steroids may be of use in
the treatment of hydrocarbon pneumonia, but this
has not, as yet, been proven. Graham,18 although
he thought cortisone beneficial in his case of
crude-oil inhalation, suggested that in the case of
inhalation of a rapidly spreading substance like
kerosene the substance may be more harmful than
the inflammation it produces. In this case, he sug-
gested, the inflammation may serve to inhibit the
spreading of the toxic material, and inhibition of
the inflammation might be undesirable. All things
considered, it would seem that the use of adreno-
cortical steroids deserves an extensive, carefully
controlled trial in the therapy of hydrocarbon
pneumonia.

REFERENCES

1. Olstadt, R. B., and Lord, R. M.: Kerosene intoxication.
AMA Am. J. Dis. Child. 83:446, 1952.

2. McNally, W. D.: Kerosene poisoning in children; study
of 204 cases'. J. Ped. 48:296, 1956.

3. Lesser, L. I., Weens, H. S., and McKay, J. D.: Pulmonary
manifestations following ingestion of kerosene. J. Ped. 23:-
352, 1943.

4. Waring, J. I.: Pneumonia in kerosene poisoning. Am. J.
Med. Sci. 185:325, 1933.

5. Foley, J. C., Dreyer, N. B., Soule, A. B., and Woll, E.:
Kerosene poisoning in young children. Radiology 62:817,
1954.

6. Richardson, J. A., and Pratt-Thomas, H. R.: Toxic effects
of various doses of kerosene administered by different routes.
Am. J. Med. Sci. 221:531, 1951.

7. Gerarde, H. W.: Pathogenesis of pulmonary injury in
kerosine intoxication. Delaware M. J. 31:276, 1959.

8. Gerarde, H. W.: Toxicologic studies on hydrocarbons V.
Kerosine. Toxicol. Appl. Pharmacol. 1:462, 1959.

9. Deichmann, W. B., Kitzmiller, K. V., Witherup, S., and
Johansmann, R. J.: Kerosine intoxication. Ann. Int. Med.
21:803, 1944.

10. Ragan, C , Howes, E. L., Plotz, C. M., Meyer, K., and
Blunt, J. W : Effect of cortisone on production of granulation
tissue in rabbit. Proc. Soc. Exp. Biol. Med. 72:718. 1949.

11. Howes, E. L., Plotz, C. H., Blunt, J. W., and Ragan, C.:
Retardation of wound healing by cortisone. Surgery 28:177,
1950.

12. Spain, D. M., Molomut, N., and Haber, A.: Biological
studies on cortisone in mice. Science 112:335, 1950.

13. Spain, D. M., Molomut, N., and Haber, A.: Effect of
cortisone on the formation of granulation tissue in mice (ab-
stract). Am. J. Path. 26:710, 1950.

14. Spain, D. M., Molomut, N., and Haber, A.: Studies of
the cortisone effects on inflammatory response. I. Alterations
of histopathology of chemically induced inflammation. J. Lab.
Clin. Med. 39:383, 1952.

15. Geiger, R. S., Dingwall, J. A., and Andrus, W. DeW.:
Effect of cortisone on growth of adult and embryonic tissue
in vitro. Am. J. Med. Sci. 231:427, 1956.

16. Nassau, E.: Uber die Behandlung der aspiration von
petroleum mit cortison. Ann. Pediat. 178:181, 1952.

17. Bass, A. D., and Setliff, J. A.: In vitro actions of steroids
on smooth muscle. J. Pharmacol. Exp. Ther. 130:469, 1960.

18. Graham, J. R.: Pneumonitis following aspiration of

crude oil and its treatment by steroid hormones. Trans. Amer.
Clin. Climat. Ass. 67:104, 1955-6.

19. Mayock, R. L., Bozorgnia, N., and Zinsser, H. F. : Kero-
sene pneumonitis treated with adrenal steroids. Ann. Int. Med.
54:559, 1961.

Vol. LII, No. 2

Journal of Iowa Medical Society

20. Arena, J. M.: Personal communication.

21. Hardman, G., Tolson, R., and Baghdasserian, O.: Pred-
nisone in management of kerosene pneumonia. Indian Practit.
13:615, 1960.

22. Holmes, A. W.: Steroid therapy in acute pulmonary
edema due to chlorine inhalation. To be published.

23. Marshall, B. M., and Gordon, R. A.: Vomiting, regur-
gitation, and aspiration in anaesthesia. Canad. Anaes. Soc. J.
5:438, 1958.

24. Prasad, B. N.: Role of prednisone in acute pulmonary
edema. Arch. Int. Pharmacodyn. 114:146, 1958.

25. Lowry, T., and Schuman, L. M. : “Silo-filler’s disease” —
a syndrome caused by nitrogen dioxide. J. Am. Med. Ass.
162:153, 1956.

26. Gailitis, J., Burns, L. E., and Nally, J. B.: Silo-filler’s
disease, report of a case. New Eng. J. Med. 258:543, 1958.

Hazards in Do-It-Yourself Laundries

An Indiana patron of an automatic laundry was
asked by his daughters, aged nine and seven years,
for two nickels with which to buy soft drinks.
When, after a few minutes, he looked for the
girls to find where they could buy such low-priced
refreshment, he found them with two unmarked
paper cups containing a clear liquid. Only the
elder girl had drunk any of it, and she had prompt-
ly spat it out. The liquid, however, turned out to be
a bleach containing up to three per cent available
chlorine. It had come from an easily operated
vending machine with a coin slot 42 inches from
the floor.

In addition, it is said that an Illinois firm has
recently circulated a letter seeking to persuade
automatic vending device operators to buy and
manage aspirin-dispensing machines.

The medical profession should be alert to this
relatively new source of poisons.

New Physician's Guide on
Anticoagulants

A new booklet to provide physicians with guid-
ing principles and practical recommendations for
the use of anticoagulant drugs has been issued
by the American Heart Association.

Entitled “A Guide to Anticoagulant Therapy,”
the booklet contains material designed to aid the
physician who has decided to institute anticoag-
ulant therapy in making the most effective use of
these drugs. It does not consider the indications
for therapy or the merits of different agents in
the prophylaxis or treatment of specific diseases.

The two types of agents currently employed —
heparin and coumarin-type compounds — are dis-
cussed with reference to their physiologic effects,
administration, contraindications and appropriate
antidotes. Fibrinolytic agents (either used alone
or in combination with anticoagulants) are not in-
cluded “because there has not been enough clin-
ical experience to permit recommendations.”

The publication emphasizes the importance of
individualized treatment, careful clinical observa-
tion, and frequent reliable laboratory tests. In ad-
dition, many common problems of anticoagulant

therapy are discussed in question and answer
form. The booklet also contains several tables
and selected references.

The guide originally appeared as an article in
the July, 1961, issue of circulation, one of three
professional journals issued by the Association. It
was prepared for the organization’s Committee on
Professional Education by Benjamin Alexander,
M.D., and Stanford Wessler, M.D., of Beth Israel
Hospital, Boston.

Copies of the booklet may be obtained by phy-
sicians from Iowa Heart Association, 2100 Grand
Avenue, Des Moines 12, Iowa.

County Societies to Get
New Public Service Ads

A new venture in public service advertising
was launched by the American Medical Associa-
tion in January.

Every county medical society was sent the first
six in a series of public service messages, with the
recommendation that these ads be placed in local
newspapers.

The ads are simple, straightforward and non-
political. Each message is “open end” so that a
medical society can add appropriate local infor-
mation. The first six ads cover these subjects:

• Choosing a family doctor

• Medical society grievance committees

• Doctor-patient relationship

• Why MDs promote immunization

• Medicine’s traditional guarantee of care for all

• Cost of medical care

Jim Reed, the AMA’s Communications Division
director, says the ads will help medical societies
fulfill their educational responsibilities to the pub-
lic and at the same time improve medical press
relations.

“For years newspaper publishers have resented
medicine’s unwillingness to buy space to tell the
people its views on specific subjects. What doctors
considered conformity to medical ethics was con-
strued as niggardliness by the press,” Reed said.

“Medicine’s traditional reluctance to call atten-
tion to itself allows many a criticism to go unchal-
lenged. Several medical societies have pioneered
by placing institutional ads in local papers. These
ads, styled as public service messages, have been
extremely well received by the public and the
newspaper profession.”

The new series of public service ads has long
been recommended by AMA’s Communications
Advisory Committee, composed of representatives
from state and county medical societies. The next
six in the series, with accompanying art work if
societies choose to use it, will be ready early in
February.

Journal of Iowa Medical Society

February, 1962

In Memoriam

Lester Davis Powell was born in Villisca, Iowa,
on March 18, 1891, and spent his early childhood
in Red Oak. After his graduation from the Red
Oak High School, he attended Iowa State College
(now Iowa State University). He then attended
and graduated, successively, from the College of
Liberal Arts and the College of Medicine at the
State University of Iowa, and in 1918-1919 served
an internship at University Hospitals, in Iowa City.

Following his graduation, Dr. Powell was, for
a short time, an assistant to Dr. Rowan, then a pro-
fessor of surgery at S.U.I. From 1919 until 1926,
Dr. Powell was at the Mayo Clinic, first as a resi-
dent in surgery and subsequently as a staff sur-
geon. He was first assistant to Dr. Charles Mayo
and Dr. W. J. Mayo. He also took special work in
obstetrics and gynecology at the New York Lying-
In Hospital under the auspices of the Mayo Clinic.

In 1926, Dr. Powell entered private practice in
Des Moines as a general surgeon, and became
a staff member at Iowa Lutheran Hospital, Iowa
Methodist Hospital and Mercy Hospital.

On December 13, 1941, he was called into active
service in the Medical Corps of the United States
Navy. He served at the Long Beach Naval Hos-
pital, at the Santa Marguerita Naval Hospital, at
Oceanside, California, and at the Pearl Harbor
Naval Hospital. When he was discharged, in Feb-
ruary, 1946, he had attained the rank of captain.

Dr. Powell was a member of the Polk County
Medical Society, of the Iowa Medical Society, of
the American Medical Association, of the American
College of Surgeons, of the Western Surgical Soci-
ety, of the Medical Library Club, of the Des
Moines Rotary Club, of the Des Moines Club, and
of the Central Presbyterian Church, in Des
Moines. He was a member of the board of the Des
Moines Health Center and at various times was
president of the Mayo Alumni Association, and of
the Polk County Medical Society, and a member
of the Des Moines Chamber of Commerce and of
the Simpson College Board of Directors.

In addition to the above, Dr. Powell was a mem-
ber of Sigma Xi honorary science research society,
Alpha Omega Alpha, honorary medical fraternity,
Nu Sigma Nu medical fraternity, and Sigma Alpha
Epsilon social fraternity. Through the years, he
was author and co-author of numerous surgical
articles.

In 1950, Dr. Powell was appointed director of
the health department of the Des Moines Public
Schools on a part-time basis, and in 1956 he be-
came the department’s first full-time director.
He retired from that position in July, 1961.

Dr. Powell’s death occurred very suddenly on
December 30, 1961, when he was 70 years of age,
as the result of a coronary occlusion. At the time
of his death he was a professor of clinical surgery
at the State University of Iowa, a consultant in

Lester Davis Powell, M.D.

surgery at the Veterans Administration Hospital
in Des Moines, and a member of the Dean’s Com-
mittee at that institution.

He is survived by his widow, Faye Ellis Powell;
a daughter, Sally Ann Alexander and a grand-
daughter, Lesley Ann Alexander, both of Owa-
tonna, Minnesota; and two sisters, Mrs. Velma
Petty, of Red Oak, and Mrs. Melinda Werisch, of
Creston.

With the passing of Dr. Powell, the medical
profession in Iowa has lost a surgeon of great
judgment and ability, and also one who upheld
the high ethical standards and integrity of the
profession.

Film on Stroke Diagnosis

A new professional film on strokes, which
stresses the need for accurate differential diag-
nosis because of therapeutic advances in the field,
has been produced by the American Heart Associa-
tion and its affiliates.

Entitled “Cerebral Vascular Diseases: The Chal-
lenge of Diagnosis,” it presents three case his-
tories involving cerebral thrombosis, hemorrhage
and embolus and depicts methods for proper diag-
nosis in each case.

The color film runs approximately 30 minutes
and is available for purchase or loan from Iowa
Heart Association, 2100 Grand Ave., Des Moines
12, Iowa.

Vol. LII, No. 2

Journal of Iowa Medical Society

Presidents Page

The Iowa Medical Society is cooperating with
Cornell University in a research project to study
the causes and effects of injuries and deaths re-
sulting from accidents involving late-model pas-
senger cars.

We consider this to be a very important and
worthwhile study, and urge physician support.

The program will be initiated on February 1,
involving 31 counties in southwestern Iowa.
Eventually, all counties will be asked to par-
ticipate in this 2-year program.

The “In the Public Interest” section of this
journal provides details on the safety program.

BOOKS RECEIVED

THE PHYSIOLOGY AND PATHOLOGY OF LEUKOCYTES,
ed. by Herbert Braunsteiner , M.D. (American edition pre-
pared and revised by Dorothea Zucker-Franklin, M.D.)
(New York, Grune & Stratton, Inc., 1962. $15.00).

THE DYNASTY, by Charles H. Knickerbocker, M.D. (New
York, Doubleday & Co., 1961. $4.50).

MEDICAL GENETICS 1958-1960, by Victor A. McKusick, M.D.
(St. Louis, The C. V. Mosby Company, 1961. $14.50).

FUNDAMENTALS OF GENERAL SURGERY, SECOND EDI-
TION, by John Armes Gius, M.D. (Chicago, The Year Book
Publishers, Inc., 1962. $11.50).

HYPERTENSION, ed. by Albert N. Brest, M.D., and John H.
Moyer, M.D. (Philadelphia, Lea & Febiger, 1961. $12.00).

HALOTHANE, by C. Ronald Stephen, M.D., and David M.
Little, Jr., M.D. (Baltimore, The Williams & Wilkins Com-
pany, 1961. $6.00) .

STRONG MEDICINE, by Blake F. Donaldson, M.D. (New
York, Doubleday & Co., 1962. $3.95).

BOOK REVIEWS

The House of Healing, by Mary Risley. (New York,

Doubleday & Co., 1961. $4.50).

Mary Risley is a lay woman who is interested in hos-
pital work. She has written the first complete history
of the hospital ever published for the lay public. The
book is modest sized, printed in large type, and de-
scribes not only the actual mechanics of hospital
growth, but correlates that development with the
changing political and social background in which it
occurred. She describes the influence of primitive medi-
cine, various civilizations and the church upon the
institutional care of the sick. She then relates the influ-
ence exerted by Florence Nightingale and recent scien-
tific advances upon the development of hospitals, and
ends with a prediction of things to come.

The book is written in a historical and philosophical
vein. The author traces various forces as they have
affected hospital care. She is less concerned with hos-
pitals themselves than with the factors that have
altered the hospitals, and thus it is only natural that
she would conclude with the concept that hospitals
have grown too large, scientific and impersonal, and
it is no less natural that she should suggest that a spirit
of kindness, thoughtfulness and forbearance needs to
be reinstilled into hospital administrators, nurses, doc-
tors and elevator operators.

Records of early hospitals are scanty, and the author
appears to have shunned the sordid details of hospitals
in the late Middle Ages, but she does leave the reader
with several general concepts about forces acting to
alter the hospital care of patients, so that one ends with
ideas rather than facts. That, perhaps, was what she
was after all of the time.— Daniel A. Glomset, M.D.

Pathology, Fourth Edition, ed. by W. A. D. Anderson,

M.D. (St. Louis, The C. V. Mosby Company, 1961.

$18.00).

The fourth edition of Anderson’s pathology is wel-
comed because of the addition of newly recognized
entities and significant discussions of the more basic
concepts and conditions. Subjects such as the carcinoid
syndrome, pulmonary alveolar proteinosis and aldo-
steronism are now included. The authors have drawn
upon new technics such as electron microscopy and
advanced histochemistry in rewriting their respective
sections.

The book is the most encyclopedic one-volume work
in the field of general pathology. It is a favorite of
medical school faculties, and it is of inestimable value
to the practicing pathologist as an initial reference.
The book is a “must” for hospital libraries. It is diffi-
cult to imagine a practicing physician to whom it
would not be useful.

The lists of references following the respective chap-
ters are well selected and include the significant works
that one should include in any further study of the
topics. A significant improvement in the fourth edition
over the third is the uniform size of the type. An
improved format also helps make the text more
readable. — David Baridon , Jr., M.D.

Trauma: Anatomy and Surgery for Lawyers, Vol. 3,
No. 3. (a bi-monthly periodical published by Matthew
Bender & Co., Inc., 205 E. 42nd Street, New York
City 17, $35.00 per year).

This series is designed to provide lawyers with
authoritative medical information for courtroom use.
Although designed primarily for lawyers, it will prove
a valuable tool to physicians who may be called upon
to testify at trials. It is well illustrated, contains an-
atomical charts for courtroom use, an extensive bibli-
ography for further research, and a medical vocab-
ulary-builder designed primarily to help lawyers learn
to speak the doctors’ language.

Volume 3, Number 3, released October 30, 1961, con-
tains an editorial by Marshall Houts, LL.B., entitled
“Impartial Medical Testimony: Ivory Tower Monster,”
which takes issue with the endorsement by the AMA
House of Delegates of the concept of nonpartisan med-
ical testimony. The editor expresses the opinion that
there is no such thing as “impartial” or “nonpartisan”
testimony by physicians because every doctor is “par-
tial” to his own opinion, and once having expressed
that opinion, he will defend it in the courtroom. He
concludes that the problem of conflicting expert testi-
mony will not be solved by discarding the adversary
system in so far as medical witnesses are concerned.

Vol. LII, No. 2

Journal of Iowa Medical Society

He suggests, further, that the medical profession be
taught not to abhor the courtroom but to feel com-
fortable in it.

Included in the same issue is an article entitled
“Anatomy and Physiology of the Skin,” by Hermann
Pinkus, M.D., of Detroit; one entitled “Contact Derma-
titis,” by Sidney Olansky, M.D., of Emory University;
and one entitled “Trauma to the Kidney,” by James
F. Glenn, M.D., of Yale University. Following the
article on contact dermatitis, the editor has presented
a complete direct and cross examination of a medical
witness on that subject which should prove valuable
not only to a lawyer who is preparing a case dealing
with that subject but also to a physician who is pre-
paring to testify on it.

In publishing trauma, Matthew Bender & Company
are providing the legal and medical professions with a
valuable and useful working tool. — Dale S. Missildine,

J.D.

The Nature of Sleep, a Ciba Foundation Symposium,
ed. by G. E. W. W olstenholme , M.B., BGh., and
Cecilia M. O’Connor. (Boston, Little, Brown & Co.,
1961. $10.00) .

The preface states that “sleep is a most attractive
subject for discussion.” The prefatory remarks con-
clude: “The Ciba Foundation will be well rewarded if
this book awakens fresh interest and stimulates new
experiments to unravel the mysteries still surrounding
one-third of our natural life.”

Neurophysiologic evidence points to the existence of
sleep-inducing and EEG-synchronizing structures in the
brain stem. In other words, there is, during sleep, a
considerable diminution in the activity of the ascend-
ing and descending reticular activating systems — a
“reticular deactivation.” One concept is that sleep ar-
rives as a process of passive reticular deactivation due
to physiologic “deafferentation.” Another concept is
that an active reticular deactivation can be produced
by descending effects from the cortex and by ascending
effects from the medulla. Additional papers deal with
measured neuronal activity in animals during arousal
and induced sleep.

A practical note is introduced by a contribution en-
titled “Electroencephalographic Detection of Sleep In-
duced by Repetitive Sensory Stimuli.” It points out
that rhythmically repeated sensory stimuli exert a
hypnotic effect, and that safety engineers should take
note of this phenomenon. Other practical matters are
discussed in “Hibernation and Sleep,” with applications
to hypothermic anesthesia.

For the most part, this volume is profoundly scien-
tific, and the presentations are accompanied by many
graphs, oscilloscopic recordings, etc. However, a few
items of useless though perhaps interesting information
can be found. The careful reader finds that “a horse
not in its own stable never lies down; it only sleeps
lying down when it is at home,” and that “a hedgehog
in Finland hibernates for seven months, but in this
country its hibernation is much shorter.” And he can
learn that men on polar expeditions, though at liberty
to sleep as long as they wished, slept no more than
eight hours at a time, on the average. Moreover, he is
told that in congenitally conjoined twins, each twin has
his own sleep rhythm, independent of the other, and
that during dreaming, there occurs a jerky movement
of the eyes.

the nature of sleep serves the useful purpose of
presenting in a single volume the current knowledge
and thinking about sleep, just as other volumes in the
Ciba Foundation Series have altogether admirably
brought together current knowledge and recent find-
ings in other areas. — John T. Bakody, M.D.

Disturbances of Heart Rate, Rhythm and Conduction,

by Eliot Corday, M.D., and David M. Irving, M.D.

(Philadelphia, W. B. Saunders Company, 1961. $8.50) .

This book is a comprehensive survey of cardiac
arrhythmias. It gives explanations of mechanisms,
physiological effects, recommended methods of therapy,
and expected results of treatment. In addition to sec-
tions that are standard in texts on arrhythmias, sep-
arate chapters are included dealing with arrhythmias
following or resulting from myocardial infarction, sur-
gery and anesthesia, and electrolyte disturbances. The
final chapter deals with the effects of 19 agents on
various problems.

Classifications of arrhythmias by type, by etiology
and by method of therapy allow easy and complete
fact-finding on all possible problems in this field. — John
E. Gustafson, M.D.

The Parenchyma of Law, by David W. Louisell and

Harold Williams. (Rochester, N. Y., Professional

Medical Publications, 1961. $12.50).

The authors, one of them a professor of law and the
other a doctor-lawyer, begin with the assumption that
due in part to the “fragmentation of learning,” there
has been a decline in understanding of the medical
profession by the legal profession, and vice versa.
Their stated purpose “. . . is to try to present to the
physician an objective view of law as it actually is
administered in the U. S., to aid him intelligently and
unemotionally to appraise its purposes, processes, fail-
ures and achievements.”

The book consists of four sections, and has a total of
16 chapter headings. The sections are entitled: “The
People Who Participate,” concerning lawyers, judges
and juries; “The Lawmakers — Public and Private,”
dealing with legislators and judges, and with the
medical profession’s self-government; “Riddles and
Realities,” covering the legal standards of diagnosis
and prognosis, trial mechanics, the doctrine of res ipsa
loquitur, the statute of limitations, the liability of hos-
pitals’ and lawyers’ contingent fees; and “Dynamics of
Change,” including sub-topics such as the law of to-
morrow and some philosophical observations on medi-
cine, law and justice.

The contrasts between the lawyer’s adversary meth-
od and the doctor’s objective inquiry are the crux of
medical-legal misunderstandings, in this reviewer’s
opinion. General medical ignorance of the law and of
specific legal procedures contributes to these misunder-
standings. The physician who makes use of the infor-
mation in this book will gain a better comprehension of
and even some sympathy for the law. It should be
pointed out that this volume is not a compendium of
answers to medicolegal problems, but rather fills an
important gap in the curricula of most medical schools.

The book is well written, and since it is slanted for
the medical reader, physicians will find it most interest-
ing. Your reviewer enthusiastically recommends it. —
John T. Bakody, M.D.

Journal of Iowa Medical Society

February, 1962

Medical Physiology, Eleventh Edition, ed. by Philip
Bard, M.D. (St. Louis, The C. V. Mosby Company,
1961. $16.50).

The eleventh edition of this excellent text has been
written by 16 outstanding authorities in special fields
of physiology. It is designed for the medical practition-
er, the student and the medical scientist, and presents
the applications of physiology to medical practice.
There are nine parts, each covering the present knowl-
edge of the physiology of one of the body systems.

Reviewing a text on so broad a subject as this is
difficult. The book certainly provides fundamental
information. A knowledge of pulmonary physiology
is necessary, for example, if one is intelligently
to interpret present-day pulmonary function studies,
and a thorough understanding of the many complex
factors in the coagulation of the blood are important to
have if one is to treat bleeding disorders wisely.

This text is a splendid reference work for the student
and for the practitioner. — Dennis H. Kelly, Sr., M.D.

One for a Man, Two for a Horse, by Gerald Carson.

(New York, Doubleday & Co., 1961. $6.50) .

This book is a souvenir, in words and pictures, of the
nostrums and health paraphernalia of long ago, of the
picturesque characters who thought them up, and of
the ingenious methods used in selling them. If you
think television advertisements for patent medicines
threaten the health or insult the intelligence of the
American citizen, reading this book will make you
think them altogether tame. One is amazed at how the
public can have been so gullible, for example, as to
spend $5,000,000 for Hadacol.

I don’t recommend this book to anyone who is look-
ing for medical knowledge, but admittedly it is enter-
taining and full of laughs. The four-color printing in
which the dozens of ads have been reproduced is
doubtless responsible for the high cost of the book,
and if the prospective buyer is interested in the history
of advertising, perhaps it is worth the price. But for
the busy physician, it is worth neither the money that
it sells for nor the time it takes to peruse it. — Leonard
G. Gangeness, M.D.

Essentials of Neurosurgery for Students and Prac-
titioners, by Sean Mullan, M.D. (New York, Spring-
er Publishing Co., Inc., 1961. $6.75).

Although some medical fields have many texts, the
field of neurosurgery has relatively few. Whatever the
reasons for scarcity of books on this specialty, however,
the present volume is a happy contribution.

In the preface, the author says: “With this book, I
have attempted to provide a framework of neuro-
surgical knowledge useful both to the student and to
the established practitioner.” The subjects discussed
include radiologic anatomy, epilepsy, brain and spinal
cord tumors, pain, head and spine injuries, interverte-
bral disc disease, aneurysms, brain abscesses, involun-
tary movements, peripheral and sympathetic nerves,
pediatric neurosurgery, and the history of neurosur-
gery. These topics are concisely presented in a con-
ventional, noncontroversial fashion.

This terse, straightforward text should be of great
value to those who would like a concise description of
neurosurgical conditions, as well as to students, in-
ternes and residents who need a convenient reference
work. — John T. Bakody, M.D.

Education in Hospital Costs

Students at Jefferson Medical College Hospital,
in Philadelphia, learn to consider the cost as well
as the need for diagnostic tests ordered for pa-
tients, according to an editorial comment in the
January 1, 1962, issue of the new york state jour-
nal of medicine. Each student, as he works as a
ward clerk, is given a list of the standard charges
for various procedures and tests. On at least two
of his patients, he keeps a running chart of the
costs of the tests and other diagnostic procedures
that are ordered. A glance at the running chart
dramatizes for each student how the total cost
adds up. Group discussions of the cost factor help
sharpen the analysis of indications for a procedure
and the evaluation of benefits to be obtained
thereby.

This concern for cost has helped stimulate dis-
cussion of the nature of the disease, the distribu-
tion of lesions, and the possibilities to be ruled
out in the differential diagnosis. The simple ques-
tions “Do we need it?” and “Why?” are not dis-
sociated from a consideration of the characteristic
picture of a disease process and of the pathologic
physiology.

When ordering studies of any sort, the students
learn to consider the total state of the patient —
including his financial situation.

“This pioneering work bears repetition in all our
hospitals,” the editors of the new york journal
declared. “Attending staffs as well need this in-
doctrination.”

W. B. SAUNDERS COMPANY features the
following recent books in their full page adver-
tisement appearing on page ix in this issue:

FONTANA and EDWARDS— CONGENITAL
CARDIAC DISORDERS
a vital statistical study to aid you in a better
understanding of malformations of the heart.

WILLIAMS— Textbook of ENDOCRINOLOGY
a definitive source emphasizing the effects of
endocrine changes on body metabolism.

1962 CURRENT THERAPY
today’s best treatments — ranging from external
cardiac massage for cardiac arrest through
current use of antibiotics in treating bac-
terial infections.

Reception Room Reading Matter

Every now and then it’s a good idea to review
the magazines and leaflets that are on the tables
in your reception room, and to throw away the
outdated ones. And while you’re at it, why not
order some new materials from the AM A?

The AMA has a number of pamphlets that can
be left for patients to read in your reception room,
or can be used as stuffers with monthly state-
ments. The following are free in whatever quan-
tities you need:

• TO ALL MY PATIENTS — a doctor-patient
leaflet explaining the types of medical services
that are often involved in treating a patient

• DO YOU LIKE MAKING DECISIONS?— a
leaflet emphasizing that it is a doctor’s judgment,
not just wonder drugs and medical machines, that
is most important in personal medical care

• THE FIFTH FREEDOM— a folder describing
the value of a patient’s right to choose his own
physician

• A FAMILY DOCTOR’S FIGHT AGAINST
SOCIALIZED MEDICINE — a reprint from look
telling how a small-town GP spoke up for private
medical practice

• AMERICA, BEWARE OF THE WELFARE
STATE — a reprint from the reader’s digest point-
ing out the perils of governmental cradle-to-grave
planning.

Write today to Mrs. Carol Brierly, director, Spe-
cial Services Division, American Medical Associa-
tion, 535 North Dearborn Street, Chicago 10, Il-
linois, for supplies of these booklets.

The Handling of Our Employers' Money

Receiving and disbursing money are two of the
more important tasks that are entrusted to the
medical assistant.

Without going into the intricacies of bookkeep-
ing, let me begin by saying that ALL income and
ALL expenditures must be recorded, regardless of
their size. A receipt should be made in duplicate
for each sum received, and the sum must be
credited to the proper account. The receipt must
show the date, the name of the individual who
has made the payment, the name of the person
whose account is to be credited, the amount re-
ceived, whether by cash or by check, the balance
due and the name or initial of the person receiv-
ing the payment. If printed receipts are used,

they bear the name of the doctor; if not, his
name should appear above the name or initial of
the person who is taking the payment.

Sufficient small-denomination bills and coins
should always be available to change a $20 bill.
That money, together with the cash receipts that
have accumulated during the day, should be kept
in a cash box or drawer in the assistant’s desk,
where it is accessible to her but out of reach of
the public.

In addition, a petty cash fund should be main-
tained for the payment of postage, express charges
and other small bills that must be met on short
notice and in cash. From $5 to $25 is usually ade-
quate for these purposes, but even though pay-
ments from this fund are small ones, a careful
record must be kept of each one. Receipts, vouch-
ers or receipted bills should be secured from the
payees, when possible, and should be carefully
kept. At the end of each month, one replenishes
the fund by drawing a check to petty cash for the
exact amount by which it has been depleted dur-
ing the month.

The medical assistant should be careful about
accepting payments by check. Even if the patient
is well known to her, she should always read his
check carefully to make sure that the date, amount
and signature are correct. If the patient is a
stranger, she should ask for credentials or iden-
tification. Social Security cards are not considered
good identification. She should never accept a
check bearing a correction.

Returned checks occasionally present problems.
Usually they have been returned for “insufficient
funds,” and the bank has either charged the
amount to the doctor’s account and returned the
check to him, or has notified him that it is hold-
ing the check for him to redeem. In either case,
the matter requires the medical assistant's im-
mediate attention.

Usually, “NSF” checks have resulted from care-
lessness, and their authors apologize embarrassed-
ly and ask that the check be sent again to the
bank, promising in the meantime to deposit
enough money to cover it. However, if the patient
is a poor credit risk, the medical assistant should
insist that he redeem the check at the doctor’s
office, and should set a deadline for his doing so.
In this connection it is useful to know that in
Iowa it is a felony to bounce a check for more
than $20. If the medical assistant is careful, she
can use that bit of information without making
an enemy for herself or her employer.

Journal of Iowa Medical Society

February, 1962

If one wishes the bank to collect from the
author of the check, it will do so for a small fee.
If the check has been drawn on an out of town
bank and has passed through the Federal Reserve
Clearing House, it may be returned together with
a request that it be sent through a second time.
If the medical assistant collects from the individ-
ual who wrote the check, she should then give the
check back to him.

A restrictive endorsement should be stamped on
the back of each check as soon as it is received.
That is done by means of a rubber stamp that
prints “Pay to the order of (name of bank) for
deposit only to the account of (name of doctor).”
Thereafter, the check is non-negotiable in case of
loss or theft.

Total receipts must be deposited daily. Nearly
all banks have night-depository slots beside their
doors and/or bank-by-mail arrangements that are
safer and more convenient than any office hiding-
place.

One should make out each deposit slip in dupli-
cate, listing the checks by city, ABA number and
amount. If more than one deposit slip must be
used, the currency and silver should be listed on
the slip bearing the total of the deposit. The add-
ing machine slip, if any, should be attached to
the deposit slip(s), and the largest demoninations
of bills should be at the top of the currency stack,
with all bills facing right-side-up.

— Helen G. Hughes

The Incidence of Peptic Ulcer

Some 2,500,000 Americans have peptic ulcers,
according to patterns of disease, a monthly pub-
lication of Parke, Davis & Company. Within little
more than 20 years, the estimated prevalence has
risen almost 600 per cent, the report says, and
though part of that rise has been attributed to im-
proved diagnostic accuracy, ulcers of the stomach
and duodenum ranked no lower than sixteenth as
a cause of death for the year 1959.

Duodenal ulcer occurs three to four times more
often among men than among women, and gastric
ulcer about twice as often. This disparity decreases
in older groups, especially beyond age 45, but in
no age group is the incidence among men less
than twice as great as among women. Peptic ulcer
has been diagnosed with increasing frequency in
females during the past 10 years, and in the ex-
perience of one gastroenterologist, according to
patterns, the incidence among children presenting
complaints of abdominal pain has increased from
6 per cent before 1955 to almost 20 per cent in the
period 1955-1960.

Another popular belief, that peptic ulcers are
more common among city dwellers than among
rural people, is contradicted by this study. In
farm areas the incidence is 16.7 cases per 1,000

people; in rural non-farm areas, 14.1 cases per 1,000
people; and in urban areas, 14 cases per 1,000 peo-
ple. Furthermore, there seem to be some sections
of the country where the disease is especially
prevalent. In urban areas, peptic ulcer is more
frequent in the West than in the Northeast, North
Central or South, but in rural areas the incidence
seems greatest in the South.

In a survey of physician opinion conducted by
the staff of patterns, 45 per cent of the doctors
interviewed blamed personality type for peptic
ulcer, 27 per cent cited environmental pressures,
24 per cent constitutional predisposition, and 6
per cent poor dietary habits. The percentages
totaled more than 100 because many physicians
blamed more than one factor. Seventy-six per cent
of the doctors interviewed discerned a seasonal
pattern in illnesses from peptic ulcer. Spring was
most frequently cited as the season in which flare-
ups occur. Fall was named by the next largest
number, and summer and winter were each cited
by only 6 per cent of the physicians.

Mar. 19-23
Mar. 19-23
Mar. 19-30
Mar. 19-21
Mar. 20-22
Mar. 20-22
Mar. 20-23
Mar. 21-24
Mar. 21-24

Mar. 22-23

Mar. 24
Mar. 24-26
Mar. 26-28
Mar. 25-30
Mar. 26-30
Mar. 26-30
Mar. 26-Apr. 6
Mar. 28-31

Mar. 29-31
Mar. 30-Apr. 1
Mar. 30-Apr. 1
Mar. 31-Apr. 1

Coming Meetings

(Continued from page 84)

Advances in Surgery. Cook County Graduate
School of Medicine, Chicago
Basic Electrocardiography. Cook County Grad-
uate School of Medicine, Chicago
Obstetrics and Gynecology. Harvard Medical
School, Boston

Dallas Southern Clinical Society Spring Clin-
ical Conference. Statler Hotel, Dallas
Pre- and Postoperative Care. Medical College
of Georgia, Augusta

National Health Forum. Pick-Carter Hotel,
Cleveland

American Association of Anatomists. Minne-
apolis

Neurosurgical Society of America. Buena
Vista Hotel, Biloxi, Mississippi
Thirty-ninth Annual Meeting of the American
Orthopsychiatric Association. Biltmore Hotel,
Los Angeles

The Heart: Cardiac Arrhythmias Symposium.
University of Kansas School of Medicine,
Kansas City, Kansas

International College of Applied Nutrition
Annual Convention. Huntington-Sheraton
Hotel, Pasadena, California

Conference on Emergencies. Presbyterian
Medical Center, San Francisco
Skin and Internal Disorders. Stanford Uni-
versity School of Medicine, Palo Alto
Clinical Reviews. Mayo Clinic and Mayo
Foundation, Rochester, Minnesota
Vaginal Approach in Pelvic Surgery. Cook
County Graduate School of Medicine, Chicago
Proctoscopy and Sigmoidoscopy. Cook County
Graduate School of Medicine, Chicago
Treatment of Varicose Veins. Cook County
Graduate School of Medicine, Chicago
Basic Internal Medicine. Cook County Grad-
uate School of Medicine, Chicago
American Dermatological Association, Inc.
(Members Only) San Marcos Hotel, Chandler,
Arizona

Cardiac Drugs. University of California, San
Francisco

Hypothermia. University of California, Los
Angeles

American Society for the Study of Sterility.
Drake Hotel, Chicago

American Psychosomatic Society. Sheraton
Hotel, Rochester, New York

Iowa Physicians Are Asked to Cooperate in the

Cornell University Automotive-Crash Injury

Research Program

During a two-year period beginning on Feb-
ruary 1, 1962, physicians throughout Iowa are be-
ing asked to participate in the automobile-crash
injury studies sponsored by Cornell University
(New York).* Since its inception, the purpose of
this research has been to collect reliable data on
the specific causes of injury to occupants of cars
involved in smash-ups, rather than on the causes
of the accidents themselves. Information from the
states that cooperated several years ago served as
a basis for the designing of passenger-protection
devices such as the seat belts, spring-proof door
latches, energy-absorbing steering wheels, pad-
ding, etc., with which automobile manufacturers
began equipping their cars in about 1955. Now,
one of the purposes of the program is to col-
lect data for use in evaluating the effectiveness of
those recently adopted safety mechanisms, as well
as in showing the need for additional protections.
Thus, only the injuries to passengers in post-1957
model cars are to be reported upon in the Iowa
portion of the studies.

Trauma produced in highway accidents is a
“disease” endemic to the Western Hemisphere
during the Twentieth Century, just as the bubonic
plague, typhoid fever and malaria were seemingly
ineradicable during previous eras. The Cornell
studies employ the epidemiologic approach, and

* B. J. Campbell, Ph.D., reported on the Cornell University
Automotive Crash Injury Research Program at the 1961 an-
nual meeting of the Iowa Medical Society, and his presenta-
tion was published in the December, 196i, issue of the jour-
nal OF THE IOWA MEDICAL SOCIETY.

Iowa is the twenty-second state in which the state
medical society, the state department of health
and the state police have agreed to cooperate. The
other states are Indiana, North Carolina, Virginia,
Maryland, Georgia, Connecticut, New York, Ver-
mont, Pennsylvania, Minnesota, Texas, Colorado,
Michigan, Arizona, California, Orgeon, Ohio, New
Mexico, Illinois, South Carolina and Wisconsin.
Cornell University Automotive Crash Injury Re-
search Studies are sponsored by the USPHS and
by the Automobile Manufacturers Association.

SEVERAL PROTECTIVE DEVICES HAVE HELPED

Thus far, the Cornell studies have shown that
these safety devices are effective in preventing or
in reducing the severity of injuries. In the injury
studies that have been done on crashes involving
the newer cars, it has been found that the in-
cidence of door-openings during accidents has
been reduced by one third. As a result, the fre-
quency of passenger ejection is down about 40
per cent, and the serious or fatal injuries have
declined about 12 per cent. Yet, door latches
haven’t been made crash-proof, and if they could
be so designed, the Cornell authorities are con-
vinced, 5,500 additional lives could be saved each
year.

When in use at the times of accidents, it is
reliably estimated that seat belts account for a 35
per cent reduction in the risk of major or fatal
injury.

To date, Cornell University has collected in-

MINNESOTA

|flOAIH [ MADISON " j WARREN

JEBRASKA? FEBRUARY through JULY, 1962

SARP,\ MILLS

WORTH | HARRISON

j CLARKE

| LUCAS

MONROE

! WAPELLO
1
1

1 DECATUR

| WAYNE

APPANOOSE

1 DAVIS
1

J __

jMEPCEfi

r,N*M

^SCHUYLER |

Periods during which all injuries sustained in accidents involving post- 1957 cars and investigated by the State Highway Patrol
are to be reported for the Cornell Automotive Crash Injury Research Project.

sufficient data for a reliable evaluation of the ef-
ficiency of automobile padding and of shock-ab-
sorbent steering assemblies, but the evidence is at
least beginning to show that the latter are lower-
ing the incidence of severe chest injuries to driv-
ers.

IOWA DOCTORS AREN'T TO SHARE IN THE STUDY
SIMULTANEOUSLY

The Iowa study is scheduled to last at least two
years, but doctors in each of the four quarters of
the state will be asked to make reports only dur-
ing the six-months period indicated for their sec-
tion on the accompanying map.

When one or more passengers in a post-1957 car
have been injured, the state highway patrolman
assigned to investigate the accident will have two
extra tasks to perform: (1) to answer certain

questions and take photographs for the Cornell
investigators; and (2) to deliver the required
number of copies of the physician’s report form
to the hospital emergency room or doctor’s office
where the injured were taken (or to the county
medical examiner for passengers killed in the
crash) .

The hospital employees will give the forms to

the attending physician, and when they have been
filled in, they will get them from him and forward
them to the State Department of Health.

The physician will find that the form which he
is asked to complete is a brief one, and since it is
anticipated that reports will be sought on no more
than one or two injured individuals per day in
the entire quarter of the state where the study is
in progress, the likelihood is small that any par-
ticular doctor will need to report on more than
two or three occasions.

The Division of Home, Farm and School Safety
of the State Department of Health will receive the
reports from the State Highway Patrol and from
the doctors (in most instances through the hos-
pitals where the patients have been cared for),
and will forward them to Cornell University.

CONCLUSION

Physicians are urgently requested to participate
in this effort, for it is aimed at solving one of the
nation’s foremost epidemiologic problems. Unless
the injuries of each person hurt or killed in a pas-
senger-car accident within the sampling area are
carefully recorded, the effectiveness of the study
and the value of the data that it produces will
be seriously reduced.

Twenty-Two Questions and Answers
About the AAGP

Here is presented, in a series of questions and
answers, a brief description of the American Acad-
emy of General Practice — its purposes, the ways
it serves general practitioners, and the reasons
why some 27,000 family physicians feel a moral
obligation to maintain membership in it.

We invite you to examine the answers to these
questions carefully, for we believe that they will
strengthen your faith in general practice and
demonstrate to you the desirability of joining in
this movement for the betterment of general prac-
tice, the medical profession generally, and the
public welfare.

1. What is a general practitioner? A general prac-
titioner is a legally qualified doctor of medicine
who does not limit his practice to a particular field
of medicine or surgery. In his general capacity
as a family physician and medical advisor, he may,
however, devote particular attention to one or
more special fields, recognizing at the same time
the need for consulting with qualified specialists
when the medical situation exceeds his own
training and experience.

2. What is the American Academy of General
Practice? It is a national association of doctors of
medicine who are engaged in general practice.
The Academy has active constituent state chap-
ters in all states, the District of Columbia and
Puerto Rico.

3. Why was the Academy formed? It resulted
from a spontaneous movement among groups of
general practitioners in a number of states who
were convinced that progress and advancement
in the general practice of medicine and surgery
were basic not only to the welfare of the people
of America but also to the medical profession.
They recognized that only a group of general
practitioners, banded together in their own or-
ganization, could accomplish the desired elevation
of standards and quality in general practice, just
as specialty groups have undertaken to achieve
the same objectives in their respective fields.

4. What are the objectives of the Academy? The
basic philosophy of the Academy is that improved
standards and quality in general practice will

greatly benefit the public and the medical profes-
sion. The objectives and purposes of the Academy,
as set forth in its Constitution, are as follows:

A. To promote and maintain high standards of
the general practice of medicine and surgery.
B. To encourage and assist young men and women
in preparing, qualifying and establishing them-
selves in general practice. C. To preserve the right
of the general practitioner to engage in medical
and surgical procedures for which he is qualified
by training and experience. D. To assist in pro-
viding postgraduate study courses for general
practitioners. E. To advance medical science and
private and public health, and to preserve the
right of free choice of physician to the patient.

5. Does the Academy’s program for improving
general practice extend beyond its own member-
ship? Yes. The Academy recognizes its responsi-
bility for helping all general practitioners who
wish to increase the quality and standards of their
work. Obviously, this is best accomplished through
membership in the Academy, but the organiza-
tion’s accomplishments in the wider integration
of general practitioners into hospital staffs, for
example, are not limited to Academy members.

Also, through cooperation with the Association
of American Medical Colleges and the AMA, the
Academy is instrumental in improving technics of
teaching the general practice of medicine in medi-
cal schools. Its sponsorship of preceptor programs
is intended, likewise, for the betterment of gen-
eral practice everywhere.

6. Does the Academy advocate that all general
practitioners be permitted to perform surgery in
hospitals? No. The Academy does advocate that
every general practitioner should have equal op-
portunity with specialists to qualify for hospital
privileges, but it believes that such privileges
should be extended only on the basis of com-
petency. The specific recommendations are con-
tained in the Academy’s manual on general prac-
tice departments in hospitals, which also out-
lines principles and procedures for integrating
general practitioners into medical staffs. Copies
can be obtained from the headquarters office.

The Academy believes that integration of com-
petent general practitioners into hospital medical
staffs is in the best interests of both the public
and the profession.

100

Journal of Iowa Medical Society

February, 1962

Members have a responsibility to provide op-
portunities for younger physicians to advance in
skill and experience in their community hospitals.

7. Is the Academy affiliated with the Section on
General Practice of the AMA? Not officially. It
does, however, cooperate with that instrumentality
of the AMA. Since 1947, when the Academy was
founded, all chairmen and secretaries of the AMA
Section on General Practice have been Academy
members.

8. Does the Academy duplicate the activities of
any other medical organization? No, not of the
AMA, of the speciality boards, or of any other
national medical group. Although it willingly co-
operates with other agencies whenever appropri-
ate and desirable, the AAGP has a program that
is aimed solely and specifically at meeting the
needs of general practitioners.

9. How many members does the AAGP have?
The membership changes almost daily, but as of
this writing the number approximates 27,000, mak-
ing the Academy the second largest medical as-
sociation in the United States. Its rapid growth is
unprecedented in the history of medical organiza-
tions.

10. How many members does the Academy ex-
pect eventually to have? The Academy has no
aspirations to become a “second AMA,” but on
the other hand, it has set no numerical ceiling on
its membership. Of approximately 82,000 general
practitioners now active in the United States,
probably less than half could meet and would
comply with the AAGP’s membership require-
ments. The Academy conservatively estimates its
ultimate membership at somewhere in excess of
35,000. With such a membership, it will continue
to rank second only to the AMA in shaping the
profession’s policies and maintaining its prestige.

An analysis of the numbers of practicing phy-
sicians in recent years clearly shows that more
than half of the active practicing physicians are
general practitioners. This finding is an indication
that the demand for general practitioners con-
tinues high, regardless of the expansion in spe-
cialty practice.

11. What is the relationship between the Acad-
emy and the AMA? The Academy recognizes the
AMA as the parent organization of the medical
profession in America. The Academy’s aim is to
work in cooperation and close harmony with the
AMA. Similarly, the AMA cooperates with the
Academy through joint representation on numer-
ous committees and councils.

12. Does Academy membership confer advan-
tages in the buying of private insurance? Yes, the
Academy has five group health and accident pol-
icies available to its members at substantially re-
duced premiums. In addition, a low-cost, high-
benefit group life insurance plan is available to
qualified members in most states.

The most recent addition to the AAGP insur-

ance program is a retirement plan offering a flex-
ible opportunity to invest in a growth-type mutual
fund, a group annuity, or a combination of the
two. Featuring low sales and administrative
charges, this new program is now available to
members in many states. Annual savings in Acad-
emy-sponsored plans exceed the membership fees
many times over.

13. How is the Academy governed? The Congress
of Delegates, made up of two members from each
constituent chapter, is the policy-making body
of the Academy. It meets annually. The Board of
Directors operates the Academy between meetings
of the Congress of Delegates, under general di-
rectives laid down by the Congress of Delegates.
Three new Board members are elected by the
Congress each year. The Board is aided in its
work by numerous commissions and standing
committees.

14. What are the requirements for AAGP mem-

bership? To be eligible for ACTIVE membership,
a candidate must be a graduate of an approved
medical school and have had a minimum of one
year's rotating internship in an approved hospital.
In addition, he must have completed one of the
following: (1) two years’ approved residency

training; (2) one year’s residency and two years
of practice; or (3) three years of active practice.

He must be a member of his state medical so-
ciety, and must be licensed to practice medicine
and surgery in the state of his residence. He must
be of high moral and ethical character, and he
must have shown interest in continuing his medi-
cal advancement by engaging in postgraduate edu-
cation. (By action of the Congress of Delegates,
physicians graduating after January 1, 1966, will
be required to have completed two years of formal
graduate training to be eligible for active mem-
bership.)

ASSOCIATE membership is available to grad-
uates of approved medical schools who are not
eligible for active membership.

15. How does the Annual Assembly benefit mem-
bers? First, it is the most important medical meet-
ing of the year — a concentrated postgraduate
course in the subjects a family physician can use
in his daily practice. It integrates scientific exhib-
its with the lecture program to give him both
visual and oral instruction. Registration fees for
members are paid by the Academy.

16. What value does the magazine gp have for
Academy members? Already accepted as one of
the “top three” in medical journalism, gp con-
centrates on the problems of the general physician
— and makes reading medical literature a pleasure
instead of a grim obligation. Access to this new
treatment of medical material is an “extra” for
Academy members, since a subscription to gp is
included in each member’s dues. To non-members,
subscriptions are $10 per year.

17. How do I apply for membership? One fills

Vol. LII, No. 2

Journal of Iowa Medical Society

101

out a nomination form and submits it either to the
state chapter’s office or to the AAGP headquar-
ters office, together with a check covering the ad-
mission fee and the state and national dues. Ap-
proved candidates, when they have been elected
by their respective state chapters, are certified to
the AAGP for membership.

18. What are the various types of membership?
ACTIVE members, as described above, make up
the bulk of Academy membership. Any member
can be given INACTIVE status by the Board be-
cause of age, illness, accident or temporary serv-
ice with the armed forces. ASSOCIATE member-
ships are available to those who are in approved
internships or residencies, and to physicians in
active practice who are unable to fulfill the re-
quirements of the By-Laws for active member-
ship. SUSTAINING memberships are provided for
those members who have ceased active general
practice but desire to continue in the Academy.

19. What are the responsibilities of a member?
Joining the Academy is evidence of a doctor’s
faith in general practice — evidence that he be-
lieves in the Academy’s objectives. The primary
obligation of active membership, of course, is the
fulfillment of the postgraduate study requirements.
Interest in the state chapter’s program is impor-
tant, and each member is urged to be equally ac-
tive in the county or district chapter in his area, or
to assist in the development of such a chapter.
Finally, the Academy hopes each doctor will con-
tribute to its continuing growth by encouraging
his colleagues to join, if he feels that they merit
such membership.

20. How much are dues? American Academy
dues are $25 per year, payable each January 1.
There is an admission fee of $10, and thus the
total for the first year is $35. (For new members,
the national dues are prorated on July 1.) State
dues and initation fees are extra, and they vary.
The exact amounts are shown on the nomination
form.

21. What must a member do to retain his mem-
bership? All active memberships terminate at the
end of three years. To be eligible for reelection,
a member must have completed 150 hours of post-
graduate training acceptable to the Commission
on Education. This requirement is based on the
principle that continuing study is the keystone of
good medical practice.

22. Does the Academy have political activities?
No. The Academy lends support to other organiza-
tions which oppose movements or legislative pro-
posals inimical to medicine and public health, but
such actions are not among its principal objectives.
It employs no lobbyists in Washington. Academy
founders rightly recognized that the family phy-
sician’s principal obligation is self-improvement
as a medical practitioner, and the Academy’s ef-
forts are directed principally at that end.

Northwest Postgraduate Conference

Sher at on-Martin Hotel, Sioux City
Thursday, March 15, 1962

All physicians and their wives are cordially in-
vited and urged to attend the Northwest Postgrad-
uate Conference, at the Sheraton-Martin Hotel,
Sioux City, on Thursday, March 15. The meeting
will be sponsored by the Iowa Chapter of AAGP,
in cooperation with Lederle Laboratories. There
will be no registration fee. All expenses of the
meeting, including those of the speakers, the lunch-
eon and the reception will be defrayed by a grant
from Lederle.

An outstanding program has been arranged.
Following are the speakers and their topics.

“Alcoholism — Acute and Chronic” — Beverley T.
Mead, M.D., University of Kentucky

“Obstetrical Emergencies” — M. E. Davis, M.D.,
Chicago

“Toxic Eruptions” — Harry N. Robinson, Jr.,
M.D., University of Maryland

“Rhinitis, Sinusitis and URI’s” — Noah D. Fabri-
cant, M.D., Chicago

“Behavior Problems in Children” — Edward M.
Litin, Mayo Clinic (the luncheon speaker)

Dr. V. L. Schlaser, the Iowa Chapter president,
will moderate the morning program; Dr. Donald
H. Kast, a member of the AAGP Board of Di-
rectors, will be the luncheon chairman; and Dr.
Eugene Smith, the president-elect of the Iowa
Chapter, will moderate the afternoon program.

Five hours of Category I credit will be allowed
Academy members for attendance at this meeting.

Excess Mortality Associated With
Epidemic Influenza*

One of the classic epidemiologic descriptions
frequently applied to influenza is embodied in the
phrase “high morbidity, low mortality.” Such a
description however tends to lose sight of the fact
that morbidity in epidemic influenza may be so
high that even the relatively low associated mor-
tality may itself reach grave proportions.

Two epidemics of Asian strain influenza have
occurred in the United States since the identifica-
tion of this antigenic variant in May 1957. The first
occurred in two distinct waves from September
through December, 1957, and from January
through March, 1958. A total of almost 40,000
excess deaths were recorded during the first wave
and of 20,000 during the second wave. During the
first three months of 1960, a second major epidemic
occurred, resulting in approximately 27,000 excess
deaths. A total of 86,000 deaths in excess of the

* Eickhoff, T. C., Sherman, I. L., and Serfling, R. E.: Ob-
servations on excess mortality associated with epidemic in-
fluenza. j.a.m.a., 176:776-782, (June 3) 1961.

102

Journal of Iowa Medical Society

February, 1962

expected number thus occurred in the United
States as a result of Asian influenza epidemics
in the three-year period.

It is important to determine in how many of the
86,000 excess deaths influenza was merely a ter-
minal event in an already severely debilitated pa-
tient, and in how many influenza and its accom-
panying pneumonia may have killed a person in
active, productive life, albeit in an older age group,
or with definite but compensated chronic disease.

The best measure of the total impact of an epi-
demic is provided by the total excess mortality.
The accompanying table shows the estimated ex-
cess, and that the bulk of it was in deaths due
to pneumonia-influenza and cardiovascular-renal
causes.

When excess mortality data are analyzed by age,
it is apparent that the heaviest toll is paid by the
population over 65 years. Although during the first
epidemic period only slightly over one half of the
excess deaths occurred in persons 65 years of age
and older, this proportion increased in succeeding
epidemics. In the 1960 epidemic, 80 per cent of the
excess deaths occurred among individuals in this
age group.

It need not seem paradoxical that an epidemic of
influenza should cause a distinct wave of excess
deaths said to be due to cardiovascular-renal dis-
ease, or to some condition other than influenza
and pneumonia. These “epidemics” of chronic dis-
ease are because deaths in the United States as
well as in most other countries are tabulated by
“primary” cause, that is the cause that initiated
the train of circumstances which eventually result-
ed in death.

EXCESS MORTALITY

IN SELECTED

YEARS (U.

S.)

Cause and Period

Expected

Observed

Excess

October-December, 1957

Total deaths

408,320

447,620

39,300

Pneumonia-influenza

12,440

24,540

12,100

Cardiovascular-renal

221,360

240,060

18,700

All other

174,520

183,020

8,500

January-March, 1958

Total deaths

421,020

441,020

20,000

Pneumonia-influenza

16,740

22,740

6,000

Cardiovascular-renal

235,180

248,180

13,000

All other

169,100

170,100

1,000

January-March, I960

Total deaths

439,100

465,800

26,700

Pneumonia-influenza

18,270

28,870

10,600

Cardiovascular-renal

246,350

258,550

12,200

All other

174,480

178,380

3,900

LIVES CUT SHORT

Analysis of the excess mortality data has sug-
gested that most victims of an influenza epidemic
are those who might have lived considerably long-
er had influenza not claimed them, rather than
severely debilitated patients in whom influenza is
simply the terminal event.

Excess influenza-associated deaths due to asth-
ma, diseases of the respiratory system other than
influenza and pneumonia, and pulmonary tubercu-
losis probably occur primarily in patients whose
pulmonary function is significantly compromised.
The lives of diabetics are jeopardized by influenza
not only by their increased risk of bacterial super-
infection and increased incidence of cardiovascu-
lar-renal disease, but also by the increased risk of
acidosis and coma during an acute infection.

An increased risk of influenza death in associa-
tion with certain conditions is better demonstrated
by clinical studies than by analysis of reported
mortality data. The association of rheumatic heart
disease and influenza-associated deaths, particu-
larly rheumatic mitral stenosis and fatal influenza-
virus pneumonia, for example, is well documented
in the literature.

A relationship between influenza-associated
deaths and pregnancy is a common clinical im-
pression. Several studies carried out during the
1957 pandemic have indicated that pregnant wom-
en are definitely at greater risk of death from in-
fluenza than non-pregnant women of the same
age group.

VACCINATION FOR HIGH-RISK GROUPS

There is a significant body of evidence that the
lethal potential of epidemic influenza is still pres-
ent. Rather than recurring in a mild form, as might
have been anticipated as the over-all immunity
of the population increased, the most recent out-
break in 1960 resulted in excess mortality which
exceeded that of the second wave of the 1957-1958
epidemic and approached that of the first wave.

This analysis serves to underscore the fact that
certain individuals are at increased risk of death
from influenza. Three broad groups can be identi-
fied— persons over 65, persons with certain associ-
ated chronic diseases, and pregnant women. The
chronic illnesses of significance include cardio-
vascular-renal disease, particularly rheumatic
heart disease; chronic pulmonary disease, e.g.,
bronchial asthma and pulmonary tuberculosis;
and metabolic diseases such as diabetes mellitus.

It would seem entirely reasonable to believe
that the prevention of influenza in these high-risk
groups would result in a corresponding reduction
of excess influenza-associated mortality. Annual
immunization of such high-risk groups against
influenza might well be highly effective in reduc-
ing the disquieting toll of excess deaths periodical-
ly exacted by epidemic influenza.

THE DOCTORS BUSINESS
How Much Fidelity Bond?

NATIONS

HOWARD D. BAKER

Waterloo

Even among the most trusted employees, and
under the most ideal system of internal control,
employee dishonesty can and does occur. If his
system is any less than ideal, in fact, an employer
may be encouraging such dishonesty. It is also a
time-worn fact that embezzlements occur in places
and at times where they are least expected. The
Fidelity and Deposit Insurance Company estimates
losses from employee dishonesty in this country
at $500,000,000 annually. Thefts range from insig-
nificant amounts up to thousands of dollars, occa-
sionally amounting to sums large enough to bring
complete financial ruin to an individual employer
or firm.

Besides providing decent working conditions,
reasonable hours, adequate wages and opportuni-
ties for advancement, employers have a moral ob-
ligation to safeguard their employees’ integrity by
doing everything possible to protect them from
the temptation to embezzle or steal. No system of
accounting or internal control has yet been devised
that will absolutely guarantee against dishonesty,
yet much can be done to keep an inherently hon-
est employee from yielding to temptation in a
moment of weakness, or under the stress of finan-
cial worry.

Following are some important features of an
adequate internal control system. If at least some
of these points are not operative in your office,
you should discuss them with your management
consultant or accountant:

1. Is the mail opened by a trusted employee,
other than your bookkeeper or cashier?

2. Is a list of payments received by mail, classi-
fied as to checks, cash or money orders, prepared
by that person and checked against the daybook
regularly ?

3. Are receipts issued for all moneys received,
and are all unused receipts accounted for as they
are used or spoiled? Receipts should be serially
numbered.

4. Is cash reconciled or balanced daily, and is it
subject to check by someone other than the person
responsible for the reconciliation?

Mr. Baker is a partner in Professional Management Mid-
west, and manager of its Retirement Planning Department.
He majored in accounting and business administration at
S.U.I., and was an agent of the U. S. Bureau of Internal
Revenue for 3!'2 years before forming his present association
in 1953.

5. Are deposits made daily of each day’s cash
receipts, intact, and is responsibility fixed on one
person for making these deposits?

6. Are all overages and shortages reported
promptly?

7. Cash withdrawals of any type are potentially
dangerous and should not be made. If such with-
drawals are made, a voucher showing the amount
and the date should be signed by the person re-
ceiving the funds.

8. Is cash physically safeguarded to prevent a
dishonest employee from blaming “outside theft”
in case of shortages?

9. Are the daybook, accounts receivable and
patient case histories spot-checked periodically for
discrepancies and irregularities?

10. Are all employees handling cash receipts
covered by a fidelity bond or dishonesty insurance?

These and other safeguards which can be in-
stalled will guarantee maximum protection against
employee dishonesty, but, as previously stated,
they cannot be relied upon as absolute protection.

Much has been said about the fidelity bond. The
next problem is “How large should it be?” After
considering the matter thoroughly, we feel that
the following simple formula for use in determin-
ing risk is valid, and can be used for dental and
medical offices: Risk = 10 per cent of annual gross
receipts plus 10 per cent of current assets (cash
on hand, bank accounts, securities, and drug and
supply inventories).

The following amounts of insurance should be
carried:

For risks up to $25,000 Equal to exposure

For risks $25,000 to $125,000 . . $25,000 to $50,000
For risks $125,000 to $250,000 . . $50,000 to $75,000
For risks $250,000 to $500,000 . . $75,000 to $100,000

Remember, no one is immune to employee dis-
honesty. Your only assurance of maximum protec-
tion is an adequate system of internal controls,
plus the bonding of each employee who has access
to moneys or valuable properties in your office.

103

STATE DEPARTMENT OF

COMMISSIONER

HEALTH

Percentage Distribution of Syphilis Cases by Age Groups,

Iowa

— 1940,

I960

and I960

Age Group

Sex

1940

Cases

Per Cent

1950

Cases

Per Cent

Cases

I960

Per Cent

Infants 1 Year

.65

.79

.27

1-4 Years

.62

.10

5-9 Years

.98

.10

10-14 Years

1.16

1.06

.18

1 1

15-19 Years

5.44

4.29

.99

1 16

20-24 Years

101

10.96

9.12

3.34

199

25-29 Years

149

14.25

8.91

3.79

241

30-39 Years

367

24.30

147

18.03

8.49

298

193

40-49 Years

339

19.95

213

21.53

15.0

207

193

103

50-59 Years

245

12.82

188

16.71

125

22.60

106

127

125

60-69 Years

108

5.59

139

10.61

140

20.88

70-79 Years

.76

2.38

12.47

80 Plus

.07

.10

2.53

1 1

Age Not Stated

2.41

6.20

9.40

Sub-Totals .

1443

52.74

983

52.14

555

50.18

1293

47.25

902

47.85

551

49.81

Grand Total

2736

1885

1 106

The U. S. Public Health Service recently ob-
served that in the fiscal year that ended on June
30, 1961, a total of 19,000 cases of infectious syph-
ilis had been reported in the United States. That
is the greatest number for any year since 1950.
The increase in early syphilis noted in most states
and major cities has not yet occurred in Iowa. Of
the 1,106 Iowa cases reported in 1960, only 51
were early syphilis (primary, secondary or early
latent) .

In 1960, of the 1,002 patients whose ages were
reported, 64.6 per cent were over 50 years of age,
as compared with 19.7 per cent in the same age
groups in 1940. This definitely indicates that in
Iowa we are now dealing primarily with peo-
ple who contracted syphilis years ago. These in-
dividuals usually have low Kolmer and VDRL
titres, and represent a definite diagnostic and
treatment problem for the physician. That they
actually do have, or have had, syphilis is borne

104

Vol. LII, No. 2

Journal of Iowa Medical Society

105

out by reactive treponemal tests (RPCF and TPI),
which in 1960 were run on all sera giving positive
standard, non-treponemal test reactions.

Iowa Influenza Surveillance

The Iowa State Department of Health, along
with all other state departments of health, since
last September, has been on the alert for out-
breaks of influenza. Outbreaks of either A or B
Type influenza had at that time been predicted by
the U. S. Public Health Service for the winter of
1961-1962. Although it seemed more probable that
outbreaks, if they did occur, would be of the Asian
A Type, to date that strain has not been isolated
from an outbreak anywhere within the United
States. The B strain, however, has been isolated
in eight different states — California, Oregon, Wash-
ington, Arizona, Colorado, Missouri, Illinois and
Florida. Two of those eight are neighboring states
—Missouri and Illinois. The disease appeared in
and west of St. Louis, and in southern Illinois
during the early part of December. Since then,
the Iowa Department of Health has increased its
alert.

No Iowa outbreaks were heard of until the
morning of January 9, when the Associated Press
carried the story of an outbreak at the Hazleton
School, in Buchanan County. Since influenza was
suspected, it was necessary to check and confirm
both the clinical and the laboratory diagnosis, if
possible. The following report is given to show
how the State Department of Health, together
with auxiliary forces, can work as a part of a
local and national surveillance program.

By noon on that same day, January 9, two
workers were ready to start to Hazleton from the
State Department of Health. One was a public
health nurse especially trained in communicable
disease control, and the other was a physician on
loan from the U.S.P.H.S. to the State of Iowa and
Polk County. Those two individuals, within 36
hours after leaving Des Moines, presented the fol-
lowing report to the State Department of Health:

“Since there is no physician resident in Hazle-
ton, we first called the city health officer for the
town of Oelwein, four miles to the north in Fay-
ette County. We also conferred with the county
health officer of Buchanan County, in which Hazle-
ton is located. Those two physicians thus were
alerted to the fact that the State Department of
Health had a work-team in the area.

“At Hazleton, the school superintendent was in-
terviewed, and he stated that on Monday, January
8, the illness really first struck, with 136 of the
350 pupils enrolled in the school ill with ‘flu.’ On
the following morning, 171 pupils were absent.
The clinical illness as described by the super-
intendent, by the patients interviewed and by
physicians in Oelwein who had seen a small num-

ber of patients was as follows: Fever from 101°
to 103° or even 105°; chills or chilliness, sweats,
non-productive cough, sore throat, runny nose,
headaches, general aches and pains, aching in the
back of the eyes and in the back of the head and
neck, and conjunctivitis. A few patients com-
plained of dizziness and nausea. There was no gen-
eral story of abdominal cramps or diarrhea. Three
patients were hospitalized at Oelwein. Duration of
illness was three to four days.

“A telephone survey was done at Hazleton, and
history forms were filled out for a total of 89 peo-
ple. This was a random survey in which every
third name in the Hazleton section of the tele-
phone directory was chosen. Hazleton has a pop-
ulation of 665. The school draws students from a
township area. All grades are included in the
school, from kindergarten through high school.
Pupils from the second grade upward were the
ones affected with this illness. There were also
some adults ill. The lower grades (kindergarten
and first) had much lower rates of infection. They
are housed in a building separate from the other
grades. They eat lunch earlier than the other chil-
dren. Therefore, there is little contact between
these two grades and other grades while at the
school. However, they ride to and from school on
buses with the other children. A breakdown was
taken of all absences and illnesses by grades and
by school staff from the superintendent's daily
record. The telephone survey gave information on
adults and pre-school children.”

Since this was largely a respiratory-tract infec-
tion, as judged by the symptoms reported, and
since fecal specimens would have been difficult to
collect, only throat washings were collected. These
were taken from 20 patients with onsets of illness
within 24 hours previous to the time when speci-
mens were taken. Because the State Department
of Health has no virus laboratory, those specimens
are being sent to the Communicable Disease Cen-
ter Field Station in Kansas City for examination.

Before leaving the area, the two investigators
met with the two county medical societies con-
cerned, and outlined to them the scope of the in-
vestigation and the procedures for the laboratory
testing. The meeting with the Fayette County
Medical Society took place in Oelwein on Jan-
uary 9, and the meeting with the Buchanan
County Medical Society was at Independence on
January 10. Doctors from those two counties re-
ported that there were a few cases of a similar
illness either to the north or to the south of Hazle-
ton. A reported outbreak in a school at Inde-
pendence was not confirmed.

On January 9, the city health officer at Maple-
ton, in Monona County, about 200 miles west of
Hazleton, phoned to describe an outbreak almost
identical with the Hazleton one. Of 850 youngsters
enrolled at a school there, about 200 were ill. He
stated that the outbreak extended into the area
surrounding Mapleton. During the week of Jan-

106

Journal of Iowa Medical Society

February, 1962

uary 15, outbreaks have appeared in rural Polk
County. These are being investigated by the Des
Moines-Polk County Health Department at this
writing.

The type of clinical illness shown in the out-
breaks in Buchanan and Monona Counties is al-
most identical with that described as influenza B
outbreaks in other states. The State Department
of Health knows, also, that Type B influenza dif-
fers from Type A in that the outbreaks do not
cover so large a territory and are inclined to be
isolated and sporadic.

Field Trials of Measles Vaccine

Field trials for two types of measles vaccine got
underway this week in some 5,000 children begin-
ning in five widely separate parts of the country,
Surgeon General Luther L. Terry of the Public
Health Service announced on December 12.

The studies are being conducted by local health
departments, in cooperation with the Service’s
Communicable Disease Center, in DeKalb County,
Georgia; Cincinnati, Ohio; Seattle, Washington;
and in Rochester and Buffalo, New York.

“This is the first large scale trial of killed virus
measles vaccine and the first time it has been used
in combination with live virus vaccine in a field
trial,” Dr. Terry said. “The purpose is to find out
how effective these methods will be in protecting
children against measles.”

Previous trials of measles vaccine, he explained,
have tested the use of live vaccine alone or in
combination with gamma globulin. The live vac-
cine alone has frequently produced fever and
rash. These side effects are reduced when gamma
globulin is used, but supplies of gamma globulin
may not be adequate for mass vaccination pro-
grams since it is derived from human blood.

Dr. Terry pointed out that in the United States
measles causes more deaths than any other com-
mon childhood disease. Conservative estimates in-
dicate that approximately 500 children die each
year as a result of infection with the measles

yOU’LL HEAR ABOUT

Casualties in nuclear-weapon warfare
at the

ANNUAL MEETING OF THE IOWA
MEDICAL SOCIETY
May 13-16

Veterans Memorial Auditorium, Des Moines

virus. Many of these deaths are due to measles
encephalitis which may occur as often as 1 in 400
cases.

The children in the current study will be di-
vided into three groups. The first group will re-
ceive three shots of killed virus vaccine. The sec-
ond will be given two shots of killed vaccine and
one shot of live. The third will receive dummy in-
jections (placebos).

Morbidity Report for Month of
December, 1961

Disease

1961

Dec.

1961

Nov.

I960

Dec.

Most Cases Reported
From These Counties

Diphtheria

Scarlet fever

195

142

165

Jefferson, Johnson, Polk

Typhoid fever

Smallpox

Measles

217

191

108

Polk, Poweshiek, Story

Whooping cough

Scott

Brucellosis

1 1

Dubuque, Polk, Scott

Chickenpox

Meningococcic

359

153

895

Buena Vista, Dubuque,
Polk, Pottawattamie

meningitis

Black Hawk, Polk

Mumps

356

350

Dickinson, Polk

Poliomyelitis

Infectious

Clinton, Story

hepatitis

148

Black Hawk, Boone, Dal-
las, Henry, Mills, Polk,
Wapello

Rabies in animals

Story

Malaria

Psittacosis

Q fever

Tuberculosis

For the state

Syphilis

100

For the state

Gonorrhea

134

145

For the state

Histoplasmosis

Dallas, Polk

Food intoxication
Meningitis (type

325

Linn (Delayed)

unspecified )

1 1

Diphtheria carrier

Aseptic meningitis

Salmonellosis

Black Hawk, Linn

Tetanus

Chancroid
Encephalitis (type

Polk

unspecified )
H. influenzal

Polk

meningitis

Amebiasis

Shigellosis

Johnson

Influenza

Dickinson

@AuMititiu eJ

Our President Says —

“The pre-eminence of a free government will he
exemplified by all the attributes which can win
the affection of its citizens and command the re-
spect of the world.”

— George Washington

“What constitutes the bulwark of our liberty
and independence? It is not our frowning battle-
ments, our bristling seacoast, our Army and our
Navy. These are not our reliance against tyranny.
All of those may be turned against us without
making us weaker for the struggle. Our reliance
is in the love of liberty which God has planted in
us. Our defense is in the spirit which prizes liberty,
as the heritage of all men and all lands every-
where.”

— Abraham Lincoln

This month we celebrate the birthdays of these
two great Americans with gratitude and humility.
Their basic ideals and their services to our country
and to humanity have increased in importance
from generation to generation, and will stand for
all time as our guideposts. May we, in 1962, hold
steadfast to their ideals in maintaining justice,
liberty, and peace.

Each of us, as an Auxiliary member, has an in-
dividual responsibility to perform. Have you par-
ticipated in the program of your county organiza-
tion? Have you paid your dues? Have you inter-
ested an eligible doctor’s wife in becoming a mem-
ber of the Auxiliary? Have you attended the sched-
uled meetings? Have you sent information on your
county’s activities to the woman’s auxiliary news?

It will soon be time for the yearly reports. That
which each of you has accomplished will deter-
mine, in a greater or lesser degree, the success
for which our Iowa Auxiliary can be credited.
Your officers are counting on you.

— Gertrude F. Kilgore, President

Annual Meeting

The Annual Meeting Committee has big plans
for your entertainment as well as for your infor-
mation at the Annual Meeting that will be held
in Des Moines, May 14 and 15, 1962. Please note
the later-than-usual dates. Be sure to mark your
calendar, so that your spring plans will include
this.

Bulletin

Be a subscriber to the official publication of the
National Auxiliary to the American Medical
Association.

U se it as a reference for your programs.

L end an issue to an Auxiliary member who
doesn’t own one.

Let’s put IOWA on the map subscription-wise.

E very county officer should take the bulletin.

T o be correctly informed, she should read the

BULLETIN.

I OWA can be in the “top ten”! Let us strive to
put it there.

N ovember-March-May-September, these are the
months in which issues appear. Please note
that the January number has been discontin-
ued.

If you have subscribed and are not receiving

your bulletin, please notify me.

■ — Mrs. George S. Atkinson
State bulletin Chairman

Membership Dues

Have your dues been sent to the state treasurer,
Mrs. John Matheson, 4321 California Drive, Des
Moines 12? They should be in her hands by March
1, 1962. Please do include 50c for the Health Edu-
cational Loan Fund (formerly Nurses’ Loan
Fund) when you send your state and national
dues, making the amount of your check $3.50.

Your bulletin subscription check in the amount
of $1.00 should be mailed directly to Mrs. G. S.
Atkinson, 1004 Third Avenue East, Oskaloosa.

Art Exhibit

The Auxiliary will again sponsor an art exhibit
open to members of the Iowa Medical Society,
their wives and all Auxiliary members. Notice of
the entry regulations, awards, etc., will be for-
warded within a short time. It is hoped that this
advance notice will help to secure even more
entries than were shown in the first highly suc-
cessful venture last year.

The art exhibit will again have space at the Vet-
erans Memorial Auditorium near the entrance to
the meeting room. There will be space available
for paintings, sculpture, drawings and graphic art.

107

108

Journal of Iowa Medical Society

February, 1962

COUNTY AUXILIARIES

MAHASKA

The Woman’s Auxiliary to the Mahaska County
Medical Society held a one o’clock luncheon at the
Downing Hotel, Oskaloosa, on Tuesday, January 9.

Mrs. Kenneth Lemon presided at the business
meeting which followed. The secretary read a let-
ter of thanks for the shipment of drugs sent to
Thailand for the Leprosy Relief Project. Thanks
were also extended to the Auxiliary through a
letter from F. O. W. Voigt, M.D., for the decorat-
ing, purchase of gifts and hostessing for the Christ-
mas party for the Mahaska County Hospital staff.

POLK

The Polk County Medical Auxiliary met for a
12:30 luncheon at the Wakonda Club in Des
Moines on Tuesday, November 14, 1961, with 175
members and guests present.

Donald McBride, M.D., medical officer for the
132nd Air Defense Wing, gave an informative talk
and answered questions pertaining to Civil De-
fense.

Mr. Ronald Reagan, motion picture celebrity,
program director for and frequent star of General
Electric Theatre spoke on the topic “Don’t Sell
Your Freedom Piece by Piece.”

Mr. Reagan presented an absorbing talk dealing
with the ever-increasing paternalism of govern-
ment and decrying the socialistic trends that have
appeared in our national life. By paraphrasing one
of Mr. Reagan’s remarks, the entire tone of his
most interesting, stimulating and enlightening
presentation may be conveyed: We may lose our
freedom all at once by succumbing to a foreign
aggressor OR we may lose it gradually by the
erosion due to socialistic changes at home.

WAPELLO

The Auxiliary to the Wapello County Medical
Society held a morning coffee, January 9, with
Mrs. H. A. Spilman, Mrs. Paul Scott and Mrs. Wm.
Maixner as hostesses.

The phonograph record “Operation Coffee Cup”
was presented during the program, and all in at-

tendance will write promptly to their legislators,
as well as to other influential people regarding
the very important subject with which it deals.
The Auxiliary voted to continue with “Operation
Coffee Cup” through the use of the record at vari-
ous coffees planned in the near future.

The new AMEF card project was discussed, and
orders for the decks of cards were taken.

The group assisted at that meeting in addressing
invitations to an open dinner program on “British
Socialized Medicine.”

1962 AAPS Essay Contest Reminder

“It is a funny thing about essay contests, but it
seems the time is never right to work on them. In
the summertime, of course, the schools are out and
the teachers are not available. In the fall there
is football and hunting and at Christmas time there
is Christmas time, etc., etc.,” from the AAPS
Newsletter of last month.

We, too, have deadlines to meet, thus a re-
minder. It is hoped that by now your schools have
been contacted and students are working on the
subject. Essays should be in the hands of the
county chairman for judging by March 1 and in
the hands of the state chairman by March 15 since
they must be at the national office by April 1 for
judging at that level.

Dr. Thomas Parker, National Essay Chairman,
closed his Newsletter with “Remember, although
it would seem that patriots should jump at the
chance to help preserve our country, some of
them need to be prodded with a hot rod to secure
the initial and subsequent jumps. Maybe a He-
frecator would do, I hope you have one!”

Good Luck! Mrs. E. M. Honke, Community
Service Chairman, 2608 Jackson Street, Sioux City
4.

Benefit Dance

Plans for the Health Educational Loan Fund
Benefit Dance are well under way. It has become
a part of the Annual Meeting to which everyone
looks forward with anticipation. It not only affords
a pleasant, friendly evening’s entertainment, but
gives all members an opportunity to help finance
health careers recruitment through the purchase
of a ticket.

WOMAN’S AUXILIARY TO THE IOWA MEDICAL SOCIETY

President— Mrs. B. F. Kilgore, 5434 Woodland, Des Moines 12
President-Elect— Mrs. A. C. Richmond, 1132 Avenue A, Fort
Madison

Recording Secretary— Mrs. F. L. Poepsel, West Point
Corresponding Secretary— Mrs. N. W. Irving, Jr., 4916 Har-
wood Drive, Des Moines 12

Treasurer — Mrs. J. H. Matheson, 4321 California Drive, Des
Moines 12

Editor of the news — Mrs. Herbert Shulman, 101 Martin Road,
Waterloo

0^ 7/ue,

IOWA MEDICAL SOCIETY

■ ■

IN THIS ISSUE:

• The Drinking and Driving Problem,

page 109

• The Search for Curable Hypertension,

page I I 7

• The Treatment of Hypertension,

page 1 28

• The Significance of Pain in the Diagnosis

of Spinal Lesions, page 1 34

• Bone Physiology, page 140

m?&.

"V.

can parallel line

U.C. MEDICAL CENTER

MAR 3 1962

San Francisco, 22

LIBRARY

Though the vertical lines appear to bow out at the bottom, the fact remains
. . . they are parallel. Similarly, when facts regarding oral penicillins are
rearranged, they may distort the true picture. Low price and high “blood
levels” are important considerations, but it’s what a drug does that counts.

V-Cillin K® achieves two to five times the serum levels of antibacterial
activity (ABA) produced by oral penicillin G.1 Moreover, it is highly
stable in gastric acid and, therefore, more completely absorbed even in the
presence of food. Your patient gets more dependable therapy for his money
. . . and it’s therapy he really needs.

For consistently dependable clinical results

prescribe V-Cillin K in scored tablets of 125 and 250 mg. or V-Cillin K, Pediatric,
in 40 and 80-cc.-size packages. Each 5-cc. teaspoonful contains 125 mg. crystalline
potassium penicillin V.

V-Cillin K® (penicillin V potassium, Lilly)

1. Griffith, R. S.: Antibiotic Med. & Clin. Therapy, 7:129, 1960.

This is a reminder advertisement. For adequate information for use, please
consult manufacturer’s literature. Eli Lilly and Company, Indianapolis 6,

Indiana.

■

m m i H H mMsm

MARCH, 1962

when the perfect combination

is threatened by a cough

MS**®

irovides She right combinafi
or effective cough contro

Your patient probably has a more “down-to-earth” occupation
than the trapeze artist, but persistent coughing can cause a
comparable drop in performance. Not so when you prescribe
benylin expectorant. This outstanding antitussive preparation
effectively suppresses coughs due to colds or allergy through
its combination of judiciously selected ingredients.
Benadryl,® a potent antihistaminic-antispasmodic, calms the
Cough reflex, relieves bronchial spasm, and reduces nasal

stuffiness, sneezing, lacrimation, other
symptoms associated with colds, and
coughs of allergic origin. Efficient expec-
torants break down tenacious mucous
secretions, thereby relieving respiratory
congestion. And the pleasant-tasting,
raspberry-flavored syrup provides a
soothing demulcent action that eases
irritated throat membranes.
benylin expectorant contains in each fJuidounce:
Benadryl® hydrochloride (diphenhydramine

hydrochloride, Parke-Davis) 80 mg.

Ammonium chloride . 12 gr.

Sodium citrate 5 gr.

Chloroform *. . . 2gr.

Menthol 0.1 gr.

Alcohol 5%

Supplied: benylin expectorant is available in
16-ounce and 1-gallon bottles.

This advertisement is not intended to provide
complete information for use. Please refer to the
package enclosure, medical brochure, or write
for detailed information on indications, dosage,
and precautions.

' PARKE-DAVIS

PARKE. DA VIS & COMPANY. Detroit 32, Michigan

Vol. Lll MARCH, 1962 No. 3

CONTENTS

A Panel Discussion: The Drinking and Driving

Problem 109

SCIENTIFIC ARTICLES

The Search for Curable Hypertension
Ray W. Gifford, Jr., M.D., Cleveland, Ohio 117

A Panel Discussion: The Treatment of Hyperten-
sion 128

The Significance of Pain and the Diagnosis of
Spinal Lesions

George Perret, M.D., Iowa City 134

Bone Physiology

David G. Murray, M.D., Iowa City .... 140

State University of Iowa College of Medicine
Clinical Pathologic Conference 149

EDITORIALS

National Poison Prevention Week 157

The Diagnosing of Pulmonary Embolism 157

Penicillin Hazards 159

Prostatectomy Routes 161

SPECIAL DEPARTMENTS

Case Studies 145

Coming Meetings 155

President’s Page 162

In the Public Interest Facing page 162

Journal Book Shelf 163

Iowa Chapter of the American Academy of Gen-

eral Practice 167

Doctor’s Business 171

State Department of Health 173

Woman’s Auxiliary News 176

Month in Washington xxxiii

Personals xli

Deaths liii

MISCELLANEOUS

Iowa Doctor’s Report From Hongkong .... 116

An Organic Theory of Mental Illness .... 133

Parkinsonism Article by Sioux City Doctor . . 144

Annual Meeting of the Iowa Thoracic Society 154
Orthopedic and Rehabilitation Seminar 161

Blank Hospital Pediatric Conference .... 164

The Socialized State 164

Stress Response to Reserpine 166

The Emerging Pattern of Urban Histoplasmosis 169

The Public’s Responsibility in Emergency Medical
Service . 170

Is There Anything Else I Can Do for You? 172

Survey Explodes Medical Myths xxx

Link Between Blood Groups and Rheumatic Fever xxxi
Organic Factor in Teenage Violence .... xl

EDITORS

Dennis H. Kelly, Sr., M.D., Scientific Editor Des Moines

Edward W. Hamilton, Ph.D., Managing Editor

Des Moines

SCIENTIFIC EDITORIAL PANEL

Walter M. Kirkendall, M.D Iowa City

Floyd M. Burgeson, M.D Des Moines

Daniel A. Glomset, M.D Des Moines

Robert N. Larimer, M.D Sioux City

Daniel F. Crowley, M.D Des Moines

PUBLICATION COMMITTEE

Samuel P. Leinbach, M.D Belmond

Otis D. Wolfe, M.D Marshalltown

Cecil W. Seibert, M.D Waterloo

Richard F. Birge, M.D., Secretary Des Moines

Dennis H. Kelly, Sr., M.D., Editor Ex Officio Des Moines

Address all communications to the Editor of the Jour-
nal, 529-36th Street, Des Moines 12

Postmaster, send form 3579 to the above address.

A Panel Discussion

The Drinking and Driving Problem

MR. CARL H. PESCH*

In approaching a discussion of the drinking driver,
I think all of us have a mistaken tendency to con-
sider the subject as a person of criminal inclina-
tions. Safety propagandists, perhaps, are largely
responsible for our attitude. They have often por-
trayed the drinking driver as no different from a
thug with a gun in his hand. They have called him
a killer, and they have called him a criminal. Al-
though there may be considerable justification for
both of those epithets, I think that they lead us
away from the man whom we must consider.

The truth is that the man who tonight may have
four or five drinks at a party, and then drive off
and kill someone, is not, this afternoon, a criminal.
At this moment he is at work, perhaps behind an
executive’s desk, a perfectly respectable member
of his community. He is the average man, the fam-
ily and church-going man. He certainly does not
consider himself a potential criminal. We certainly
could not consider him a criminal if we happened
to meet him this afternoon.

Yet, he is the very man whom we shall be talk-
ing of shortly. He is the man who has a few drinks
only once in a while. He is the man who will drive
after drinking because he can’t really believe all
the safety propaganda against that act has been
directed at him. We’ve been talking about crim-
inals, killers, thugs. Certainly he isn’t one of those.
And so, once in a great while, he drinks and then
drives. He is the man who turns up most often in
our records of fatal accidents involving a drinking
driver.

When we tag the drinking driver as a criminal
killer before the act, we automatically excuse 99
per cent of our audience from the necessity of
paying attention to what we are saying.

I’m sure no man in my audience would consider
for a moment that he is potentially a criminal
killer. Yet, I’m equally sure we could find that
several in this or in almost any other group have
occasionally driven cars after taking several
drinks. The average person simply will not identify
himself as tonight’s drunken driver — even though
that same average person may turn out to be so,
and even though he, himself, is quite aware of
that possibility.

This refusal to face facts has far-reaching sig-

* This discussion occurred at the 1961 annual meeting of the
Iowa Medical Society. Mr. Pesch is commissioner of public
safety for the State of Iowa.

nificance. It not only aggravates the drinking-
driver problem but actually prevents the adoption
of laws designed to curb this abuse satisfactorily.
The average male citizen envisions himself as the
defendant in a drunk-driving case, and for that
reason is reluctant to see measures passed that
will make evidence easier to obtain or penalties
greater than they have been. After all, according
to our mores, taking an occasional drink is a
convivial, social and manly thing to do, and the
convenience of driving home afterward isn’t some-
thing that any of us wishes to deny himself, either.
Thus, the average man feels that really tough laws
would be unfair to himself, the respectable occa-
sional drinker.

In consequence, whenever an approach is made
to strict legislation or to the enforcement of laws
already on the statute books, two things happen.
First, supporters become suddenly less numerous
than they were expected to be. Second, from sev-
eral quarters one hears the contention that civil
liberties are being infringed.

As an attorney, I am extremely conscious of the
constant need to defend the rights of the individ-
ual. I feel, too, that this defense is a particularly
grave responsibility for any administrative depart-
ment in the state or federal government. But I
recognize, too, that the rights of the individual
shrink dramatically as he increases his potential
to do harm to the innocent. That is what happens
when this afternoon’s respectable man climbs into
his car tonight after four or five drinks. He limits
his individual rights the moment he touches the
steering wheel.

Here in Iowa, as many of you know, we have
developed a strict policy toward the drinking or
drunken driver. It calls for suspension of the driv-
er’s license for one year upon arrest and before
trial. The action is taken upon the presentation of
satisfactory evidence by enforcement officers to
the Department of Public Safety. This policy has
been supported by a decision of the Iowa Supreme
Court. But I recognize that this policy is essentially
a stop-gap measure to compensate for inadequacies
in the law. What is needed in legislation will, I
think, be stressed by the other panel participants.

I have tried to point out to you that the people
involved in the drinking-driver problem aren’t
limited to a small criminal group. It is a problem
that tonight, next week or next month may involve
one of us.

109

110

Journal of Iowa Medical Society

March, 1962

DR. HORACE E. CAMPBELL*

I should like to indulge in a bit of autobiography,
if I may. In the spring of 1953, when I first became
a member of the Automotive Safety Committee of
the Colorado Medical Society, and for some time
thereafter, the thing that appealed to me partic-
ularly was the possibility of changing the pattern
or frame of reference in which accidents occur,
and I concentrated my attention upon ways of im-
proving automobile design so that the vehicle
might crash without inflicting so many and such
serious injuries. Then, while I was in Montreal at
a meeting that dealt with the subject, I met the
director of the attorney general’s laboratories for
the Province of Ontario. I asked him to tell me,
in just three or four sentences, the crux of the
alcohol aspect of the auto-crash problem, for I
hadn’t spent any time thinking about that phase
of the subject, and it hadn’t appealed to me as
one in which I might become particularly inter-
ested.

That Canadian executive told me, “You people
south of the border are trying to do the impossible.
You are trying to control the alcohol problem with
a blood-alcohol reading of .15 per cent, and that is
just simply hopeless.”

“What do you mean by .15 per cent?” I asked
him.

Your laws,’ he replied, “state that a man isn’t
really under the influence of liquor until his blood
alcohol reaches .15 per cent, and it is completely
hopeless to control the alcohol-driving problem by
using so high a percentage.”

Consequently, during the spring of 1955, I began
to study this aspect of the problem, and I began
to realize not only that my Canadian informant
had been right but that the responsibility for our
error, here in the United States, rested with the
medical profession and the American Medical As-
sociation. In 1938, the AMA had been asked for
the blood-alcohol percentage that represents in-
toxication, and the committee assigned to submit
some figures had concluded that a man whose
blood alcohol measures less than .05 per cent
should not be deemed under the influence of
liquor, but that a man whose percentage equalled
oi exceeded .15 should be regarded as showing
prima facie evidence of being under the influence
of liquor, in so far as his driving ability was con-
cerned. The committee went on to say that blood-
alcohol figures in the broad range between .05 and
.15 per cent should not be regarded as prima facie
evidence, but that in such instances the other cir-
cumstances should be considered in determining
whether the individual was culpable.

Now, just what do these figures mean? Frankly,
though I was then a physician of rather many

^ampbell is chairman of the Automotive Safety Com-
mittee of the Colorado Medical Society, a member of
ber of thcdr Cltl?f.ns Traffic Safety Committee, and a mem-
Safety Council tt6e °n Alcoho1 and °rugs of the National

years’ experience, I didn’t know until I was
taught. A 150-pound man who has a blood alcohol
of .05 per cent has as much alcohol circulating in
his system as can be found in two ounces of 100-
proof whiskey, or in two bottles of 4 per cent beer,
and isn t badly affected in so far as his driving
ability is concerned. What is .15 per cent blood
alcohol? Of course it is exactly three times .05 per
cent, but in order to acquire it a man probably
has had to consume more than six ounces of 100-
proof whiskey or eight ounces of the 80-proof stuff.
He may have had to consume eight ounces of 100-
proof liquor, for there will have been a certain
amount of oxidation in the lines and alcohol-loss
by breathing.

In other words, to attain a blood-alcohol reading
of .15 per cent, one must have consumed at least
eight ounces of 80-proof or six ounces of 100-proof
liquor within the previous hour.

Now, no one whom I know can drink eight
ounces of 80-proof whiskey and then drive ade-
quately. Most of the men in my profession say that
they don t want to drive after having had three
drinks. They are not willing to drive after having
had even two drinks unless they have eaten a
meal and at least a couple of hours have elapsed.
Yet at the moment, almost every American state
that has a law designed to keep drinking drivers
off the road has set the minimum blood-alcohol
percentage at .15. Just as Dr. Ward Smith, of
Canada, declared, we are trying to do the impos-
sible south of the border. We must revise that per-
centage downward.

During the last couple of years, a movement has
been started to reduce the blood-alcohol minimum
to .10 per cent. New York has already passed a
law to that effect, and the AMA and the National
Safety Council are recommending to their respec-
tive state groups that the official limit be changed
to that figure. Even that, however, is too high.

Ever since 1926, Norway has had a law stating
that any person whose blood alcohol is .05 or
greater shall be deemed unable to drive an auto-
mobile, and anyone found driving when his blood
alcohol exceeds that figure is jailed for 21 days.
My daughter was over in Sweden with the State
Department for a couple of years, and she tells
me that when she was on a date with a Swedish
boy, he didn’t walk near the curb if he had had
something to drink. He walked near the sides of
the buildings, for if the police find a fellow with
.05 per cent alcohol in his breath standing along-
side a car and with an automobile key in his pos-
session, even though it isn’t the key to that par-
ticular car, they bring a charge against him, and
there’s a chance of his spending the next three
weeks under lock and key.

The Swedes and the Norwegians are still heavy-
drinking nations, but they don’t drink and drive.

I have talked with many Swedes and with a great
many American doctors who went to Sweden for
the meeting of the American College of Surgeons

Vol. LII, No. 3

Journal of Iowa Medical Society

111

in Sweden, and have been told each time that it
is just the accepted thing there that the fellow who
drives doesn’t drink, and every hostess, in conse-
quence, prepares a big pitcher of orange juice to
serve to the non-drinking drivers. Those boys may
drink tomorrow, but they aren’t drinking tonight.

That is civilized behavior, to my way of think-
ing, and it is the kind of behavior that we must
insist upon in this country. A person who has had
two beers shouldn’t drive. You may protest, “Two
beers don’t do anything to me,” but it has been
shown again and again, in driving tests at
Bloomington, Indiana, up in Canada and over in
Stockholm, that accustomed drinkers who have
been given two ounces of 100-proof whiskey or two
beers can thereafter be picked out on the basis of
the way they drive.

Now, let’s turn to another aspect of the matter.
The National Safety Council advertises that seven
per cent of all drivers involved in fatal accidents
have been under the influence of liquor at the
times of their mishaps. It has publicized that figure
through exhibits at various medical meetings that
I have attended, and I have remonstrated with the
organization’s representatives about it. The point
is that the National Safety Council’s figure is based
on that same old .15 per cent blood alcohol. If a
man’s blood alcohol isn’t up to .15 per cent, he is
not under the influence according to the laws of
most states, and thus the official records show
that only seven out of every 100 drivers in fatal
accidents have been intoxicated at the times of
their accidents.

I have some figures that were collected by vari-
ous individual states. Delaware, Maryland and
New Jersey are the ones that have made really
accurate studies on the people who are being
killed in automobile crashes. For example, blood
alcohol is tested on the body of everyone who has
died of an automobile crash in the State of Mary-
land. The results show that 60 per cent of those
individuals had been drinking, and 50 per cent of
all those tested — not 50 per cent just of those who
had been drinking, but 50 per cent of all drivers
involved in fatal accidents — have had blood-alcohol
percentages of .15 or more.

In Cuyahoga County, Ohio (Cleveland), the
coroner has told me, “Blood is drawn for blood-
alcohol determinations from every fatality received
at this office, if the victim is over 15 years of age
and has survived less than 12 hours following the
accident. Under this policy, 55 per cent of vehicu-
lar-accident victims in this County were tested
during the 19-year period from 1937 to 1955. In
that length of time, alcohol was found to have been
present in 46 per cent of the pedestrians, in 54
per cent of the drivers, and in 42 per cent of the
passengers.” Now it must be pointed out that in
the course of 12 hours, an alcoholic content that
may have been considerable at the time of the

crash can have dissipated. Thus, the Cleveland
test may have proved nothing when performed on
individuals who died nearly half a day after their
respective automobile crashes. If anything, then,
the Cleveland figures are low.

In Maryland, the examination has been per-
formed only on the corpses of individuals who
died within six hours of their accidents, and those
who had a chance to metabolize most of their al-
cohol before dying have thus been eliminated from
the test group. The findings in that state, as I
have said, are that 64 per cent of drivers involved
in fatal accidents had been drinking, and that 50
per cent of them had blood-alcohol percentages
of .15 or more.

What are we to conclude from these statistics?
These figures simply show that the drinking driver
is the largest single factor in our traffic death
and injury problem. You can talk about defective
brakes, about poor lighting on the highways, and
about the driver’s frame of mind or emotional
state, but when you examine the figures sum-
marizing the chemical tests that have been made
upon drivers involved in fatal accidents, you must
conclude that alcohol is the most important cause
— at least as important, indeed, as all of the other
causes combined!

We must begin to face this problem realistically.
We must adopt legislation to characterize the
drinking driver as the individual whose blood
alcohol is, at the very most, .10 per cent. If we
were to be as reasonable as the Swedes and Nor-
wegians have been for almost half a century, we’d
have to set the limit at .05 per cent.

REFERENCES

1. Gonzales, T. A., and Gettler, A. O.: Alcohol and pedes-
trian in traffic accidents, J.A.M.A., 117:1523-25, (Nov. 1)
1941.

2. Press Release No. 7, January 28, 1958, Police Department,
City of New York, 240 Centre St., New York 13, N. Y.

3. McCarroll, J. R., and Haddon, W.: A Controlled Study
of Fatal Automobile Accidents in New York City, to be
published.

4. Haddon, W., Jr., and Bradess, V. A.: Alcohol in single
vehicle fatal accident, J.A.M.A., 169:1587-93, (April 4) 1959.

5. Gerber, S. R.: The Role of the Coroner in Motor-Vehicle
Deaths. Clinical Orthopedics, No. 9, page 303. Philadelphia,
J. B. Lippincott Company, 1957.

6. Traffic Safety, October 1957, page 8.

7. Six Months of Deaths in Maricopa County: January 1
to June 30, 1958, Maricopa Safety Council, Phoenix Arizona.

8. Accident Facts, National Safety Council, 1956, page 53.

9. Accident Facts, National Safety Council, 1957, page 51.

10. Annual Reports of Department of Post Mortem Examin-
ers, State of Maryland. 1950-59, inch, Russell S. Fisher, M.D.,
Chief Medical Examiner, 700 Fleet St., Baltimore 2, Md.

11. Freimuth, H. C., Watts, S. R., and Fisher, R. S.: Alcohol
and Highway Fatalities, Traffic Safety Research Review, June
1960, pages 23-25.

12. Wilentz, Wm. C. : Resume of Annual Reports of the
Chief Medical Examiner of the County of Middlesex, State
of New Jersey, 1933-1959, Perth Amboy, N. J.

13. Kirwan, W. E.: Alcohbl and the Police — Statistical Re-
sults Report, 1959, Bulletin of Bureau of Criminal Investi-
gation, New York State Police, Vol. 25, No. 2, 1960, pp. 10-12.

14. Highway Safety Report, State of Connecticut, Depart-
ment of State Police, 1959, page 14.

112

Journal of Iowa Medical Society

March, 1962

THE ROLE OF ALCOHOL IN FATAL TRAFFIC "ACCIDENTS”

Blood

Refer-

Data

Fatal

Driver

Drinking

Alcohol

ence

Region

for

Acci-

Fatal-

Drivers

Over

0.05-

0.01-

No.

Reported

Years

dents

ities

Per Cent

0-15%

0.10%

0.15%

0.04%

N.Y. City

1928-

1937

215

50%

1957

55%

1959-

I960

34*

50%

Westchester

1950-

County

1957

•

83 1

49%

56%

20%

Cleveland

1937-

1955

885

40%

12%

Montana

1956

134

Maricopa

Jan.-

Co., Ariz.

June

1958

60*

Delaware

1955

Delaware

1956

33 %§

58*

43 %§

Maryland

1950-

including

Baltimore

1959

983

40%

22%

1 1

Baltimore

1951-

1956

156

37%

21%

Middlesex

1948-

Co., N. J.

1959

264

17%

33%

State of
New York

1959

9211

51%

75%

33%

State of
Conn.

1959

361!

* Dying within six hours of the crash.

* Single-vehicle accidents, with death within 4 hours.

* Pedestrian fatalities eliminated.

' Sixty-two per cent of the drinking drivers had blood alcohol readings over 0.15 per cent.
II One-car fatal accidents, with death within 24 hours.

Vol. LII, No. 3

Journal of Iowa Medical Society

113

MR. RICHARD L. HOLCOMB*

I shall talk about the various tests for intoxica-
tion. The breath test is not a new technic. Indiana
started using it in 1937, and has used it continu-
ously ever since. I am quite sure that there are
more breath tests given for intoxication than there
are blood and urine tests combined. I, myself, used
the breath test when I was on the staff of the
Kansas City, Missouri, Police Department, and I
demonstrated it and ran 3,900 tests with it at the
automobile show in New York City in 1939 — 22
years ago.

The whole principle of the breath test is that
alcohol, after a relatively short time, is uniformly
distributed throughout the body, and that any
body fluid or tissue can then be relied upon to
have an amount of alcohol in it that is proportional
to the water content of that particular material.
Further research showed that 2,100 parts of
alveolar air contained the same amount of alcohol
as could be found in one part of blood. Now that
ratio was the subject of a certain amount of con-
troversy, but the matter was reinvestigated by
the parties to the dispute, and they finally agreed
upon 2,100 to 1 as the correct figure.

Alcohol, of course, is the only substance to be
found in the breath in any appreciable quantity.
Ether or acetone can be found there, under some
circumstances, but if one of them is found in the
breath of a driver who is being tested for in-
toxication, the situation is most unusual. It occurs,
I think, only as a fabricated defense against a
charge of OMVI, rather than for any really good
reason.

If the subject’s breath changes the color of the
substance used for the test, a significant amount
of alcohol is present. With the Drunkometer, one
measures the volume of breath expelled into the
instrument in reaching the end point. With some
of the other instruments such as the Breathalyzer,
the subject expels a measured amount of breath
into the instrument, and then the degree of color
change in the chemical is measured photometrical-
ly. The Drunkometer uses an acid solution of
potassium permanganate. In the Breathalyzer, po-
tassium di chromate is oxydized down to potassium
chromate, and the consequent change from yellow
to green is photometrically computed.

The Breathalyzer is the newest of the chemical
tests, although it has been commercially available
for six or seven years and was under development
for about 10 years before that. It was developed by
Robert Borkenstein, who heads the Indiana State
Police Laboratories and is a highly competent
chemist. I think it is by far the best instrument
from the standpoint of simplicity of operation and,
moreover, permits the least chance of any sort
of error.

* Mr. Holcomb, of Iowa City, is an associate professor and
chief of the Bureau of Police Science at the State University
of Iowa, and a member of the Committee on Alcohol and
Drugs of the National Safety Council.

The potassium dichromate in the acid solution
comes from the supplier in sealed ampules. Each of
them has a control number on it, and its contents
have been analyzed by several chemists at the
factory. Those men have made complete records
on the chance of their being called upon to testify
in court as to the accuracy of the compounding.
Potassium dichromate is the only chemical that the
Breathalyzer uses, for there are no permanent
chemicals in the instrument. It has a shelf life so
long that there is no need for worry about its de-
teriorating before it is used.

One inserts the ampule that he is going to use
for the test, after breaking off the tip, and he uses
another ampule as a control. They simply drop into
the instrument. Then one takes a small bubbler
tube that comes sealed, hooks it up, and drops it
down into the test ampule. Then the instrument
is allowed to heat to body temperature, or slightly
above. There is a thermometer in the instrument so
that the operator can make sure he is working at
a temperature between 45 and 50° C. If so, there
will be no vaporization of alcohol out onto the
walls of the instrument.

After dropping the ampules into the instrument
and connecting them, one flushes out the system
with a bulb, pumping air into the entire apparatus
so that the defense can’t claim that some alcohol
could have remained in the instrument from the
breath of the subject last previously tested. Next,
one turns on the light in the photometer and bal-
ances the two ampules against one another, to
make sure that the same amounts of light are
reaching both of the photoelectric cells. By this
maneuver, the operator makes sure that he is
starting the test from a known point.

A spit-trap is hooked up to catch any excess
saliva. It is a one-use, disposable thing. The tube,
which has been allowed to become warm, is pulled
out, and the subject is told to blow through it and
to continue blowing. He can start with no more
than a medium breath, or if he wishes, he may
take an especially deep breath.

As the subject blows, the air enters a small
cylinder containing a piston. His breath raises the
piston to the top of the cylinder, and when the
piston has passed a couple of holes, the air passes
on out through the remainder of the instrument.
When he quits blowing, the piston drops back
just far enough to cover the two holes. Thus it has
captured a known sample of air — about 52 cc. —
and since it is from the “end” of the subject’s
breath, it has come from his alveoli, where the
ratio of alcohol to air is constant.

The next step is simply to turn the knob on the
top of the machine to the “analyze” position. The
weight of the piston then forces the air or breath
through the chemical. The color change takes
place, and then one again centers the photometer,
zeroing it this time by turning a knob on the top
of the instrument. In doing so, one also swings a
hand across a scale that is calibrated directly in

114

Journal of Iowa Medical Society

March, 1962

percentages of blood alcohol. Under that scale is
a removable chart, and by depressing a rubber
pointer one transfers the test result to it for use
in court.

Now it has taken me longer to describe this test
than it takes to give it, but let me tell you another
precaution. On each test record is a list of the steps
involved in the test, and as the operator performs
each of the operations, he checks it on that list.
The record contains spaces also for the name of the
subject, the blood-alcohol reading, the ampule
number, the date, the name of the operator, etc.
for verification of the findings in court.

Actually, the term breath test is a misnomer, for
the procedure is really a blood test. The breath
serves only to carry the alcohol from the blood
to the collecting device. The technic is a great deal
simpler than the one that requires sticking a
needle into the subject, pulling out a blood sample,
sending it to a laboratory and having the alcohol
isolated by means of distillation, dessication or
aeration. The breath test takes no more than a mo-
ment, only a single step is involved, and only a
single technician is required in performing it.

In various parts of the country the accuracies
of breath, urine and saliva tests have been com-
pared, and it has been found that the results are
as nearly identical as are the results of any two
successive blood analyses. Furthermore, with the
breath tests there is much less chance for con-
fusion or other sorts of error.

The Drunkometer was developed by Dr. Harger,
at the Indiana University Medical School, for the
purpose of determining whether or not the uncon-
scious patients brought to the University Hospital
emergency room were unconscious because of
injury or illness, or were dead drunk. Since he was
also state toxicologist, he saw the applications of
his device for police work, but like Dr. Harger,
you Iowa physicians may find it useful in solving
some of your own problems.

Let’s suppose that an unconscious patient is
brought to you for care. You find that he has all
the symptoms of intoxication — chiefly a strong
odor of alcohol about him. If you had a breath-
testing device you could answer the question
instantaneously. Clinical signs of this sort can
have any of several explanations. The commonest,
judging from police experience at least, is that the
patient is a diabetic, but the other possibilities in-
clude a light stroke or a head injury in which there
has been minimal bleeding from the scalp. A
breath-analysis device could give you an immedi-
ate answer, as far as intoxication is concerned.

Dr. Campbell has commented on the importance
of intoxicated drivers in our traffic problem. I have
been working in this field since 1937, I have done
considerable research on the effects of liquor on
driving ability, and I have visited the scenes of a
great many accidents. As far as I am concerned, it
is time for us to quit fooling around with drunken

drivers. Actually, I can see no acceptable alterna-
tive other than the Scandinavian laws that Dr.
Campbell has described.

MR. WILLIAM N. PLyMAT*

I should like to add a few statistics to the ones
that Dr. Campbell has presented, reemphasizing
the fact that alcohol is by far the greatest single
cause of our traffic-accident problem.

Studies made in Evanston, Illinois, and else-
where have indicated that somewhere in the neigh-
borhood of 12 per cent of all drivers on our high-
ways actually have been consuming alcohol, though
less than .5 per cent of that number have enough
alcohol in their blood so they might be convicted
of drunken driving. Yet, Dr. Campbell’s report that
50 per cent or more of fatal-accident drivers had
consumed alcohol is altogether credible. The im-
portant thing that we should look for is the per-
centage at which impairment begins. Studies in
Sweden and in Canada have shown that it starts
when there is .03 per cent of alcohol in the blood,
and the Swedes say that when the percentage
reaches .05, driving ability has been impaired by
30 per cent.

In Montana during 1955 and 1956, a total of 438
persons were killed in 347 automobile accidents.
Blood samples were obtained from 202 of those
victims, but in 14 cases the samples had been con-
taminated by embalming fluid and had to be dis-
carded. Of the remaining 188 sampled, 23 per cent
showed under .05 per cent blood alcohol; 31 per
cent showed between .05 and .15 per cent; and 46
per cent showed .15 per cent or more. It can be
seen from those figures that substantial deteriora-
tion in driving ability must result from the con-
sumption of enough alcohol to produce percentages
between .05 and .15.

Our statutes on this subject are vague and in-
definite. The offense of which people are accused
is, for all practical purposes, “drunk driving,”
something that is just as capable of varied inter-
pretations as were the “unreasonable and im-
proper” speeds for which our Iowa courts were
asked to punish people under laws that were on
our books until just a few years ago. Every juror
has a different notion of what drunkenness is. In
a large number of states, the drunk-driving stat-
utes have been fortified by supplementary regula-
tions known as “statutory presumptions.” Under
these, blood-alcohol percentages in excess of .15
are called presumptive evidence of violation, per-
centages less than .05 are called presumptive evi-
dence of innocence, and percentages between those
two figures are said to constitute evidence that
shall be considered along with other facts in the
case. Now Iowa is among the handful of states that

* Mr. Plymat, of Des Moines, is president of the Preferred
Risk Mutual Insurance Company, a member of the Iowa Bar,
and a member of the Committee on Alcohol and Drugs of
the National Safety Council.

Vol. LII, No. 3

Journal of Iowa Medical Society

115

don’t have even these statutory presumptions.
Iowa has nothing in this area!

In the present state of affairs, Iowa enforcement
officers have learned through sad experience that
except in very unusual circumstances they’d better
not charge anyone with drunken driving without
being able to show that the accused had a blood-
alcohol percentage in excess of .15 per cent, for
otherwise he’ll certainly be found not guilty. This
means that in this state our effective legal limit is
three times higher than it ought to be.

Now I come to the question of what action we
should take in solving this problem. The plain fact
is that a large number of the people who are drink-
ing and driving will persist unless there is a precise
legal system under which they will be punished
for doing so. What we need to do, I think, is to
approach this problem in the same way that we
have approached the problem of regulating speed.
We now have speed limits in terms of miles per
hour, and we need blood-alcohol limits, along with
statutes that will insure the measurement of blood
alcohol whenever our law-enforcement officers
think it advisable.

Nine states, thus far, have passed “implied con-
sent” laws. They are New York, Kansas, Utah,
Idaho, North Dakota, South Dakota, Nebraska,
Vermont and Rhode Island. Many others are con-
sidering them. When a proposal of this sort was
made in the Iowa legislature, a protest arose about
its infringing upon the rights of drivers. I should
say that our legislators have more reason to con-
cern themselves with the rights of drivers in gen-
eral than with the rights of those who wish to
drink and drive! The proposed statute doesn’t re-
quire absolutely that drivers must submit to the
test, but imposes a strong penalty on the driver
who refuses. We must remember that a large num-
ber of drivers are not going to stop drinking in
order to protect your life or even their own, but
will stop drinking to safeguard their licenses. If this
type of legislation is passed, it seems rather clear
that it will save a substantial number of lives in
Iowa.

The insurance company with which I am associ-
ated has written and has widely distributed a
model bill that incorporates the two highly desir-
able features to which I have referred, and also
includes a section designed to make sure that the
test will be given only by competent persons, as
well as other similar safeguards. As regards the
alcohol content of a driver’s blood, it delineates
three separate offenses, one for percentages be-
tween 0.5 and .10; one for percentages between
.10 and .15; and one for percentages equal to or in
excess of .15. In addition, it sets a penalty for the
fellow who has refused to submit to the test.
Copies of this model act are available from my
firm on request.

Here is how such a measure would work. A
driver who had been found to have between .05
and .10 per cent blood alcohol would be fined be-

tween $50 and $250, but would not be jailed or
deprived of his driver’s license. One with a per-
centage between .10 and .15 would be fined be-
tween $100 and $250, and/or would be sentenced
to jail for anywhere from two to 30 days. In ad-
dition, his license would be suspended for 90 days.
A driver who was found to have had .15 per cent
or more of blood alcohol would be fined between
$250 and $1,000, and/or jailed for anywhere from
five days to a year. His license would be suspended
for 90 days. The driver who was accused but was
unwilling to take a breath test would, on convic-
tion, be fined and given a jail term ranging from
five days to a year, and his license would be
suspended for 90 days.

Let’s take a hypothetical example. A police offi-
cer stops a driver whose car has been weaving
noticeably, and smells liquor on his breath. He
tells the man that if he refuses to take a breath
test, his license will be suspended.

“What’s the penalty for driving after drinking
just two beers?” the prisoner asks.

The officer tells him that if he has been drinking
as moderately as that, he is almost certain to go
free.

“What happens to a man who has had four
beers?” the prisoner wants to know.

The officer tells him the penalties.

“If I don’t take the test and yet am convicted,
what will I get?” the man asks.

“In that case,” the officer replies, “you’ll really
get it.”

Under these circumstances, it seems to me that
most people would agree to take the test.

What would be the effect of such legislation on
drivers generally? I think that even the man who
is convinced that he can drive adequately after
four to six shots would no longer take the risk of
doing so. He could be relied upon to treasure his
driver’s license, his pocket book and his liberty too
greatly. Such a change in attitude is what I choose
to call “driver orientation.” A system of exact
standards, plus implied consent for breath tests,
will create in these people a willingness either to
quit drinking or to forego driving after drinking.

YOU'LL HEAR ABOUT
Casualties in nuclear-weapon warfare
at the

ANNUAL MEETING OF THE IOWA
MEDICAL SOCIETY
May 13-16

Veterans Memorial Auditorium, Des Moines

Sowa Doctor's Report From Hongkong

As a member of the Iowa Medical Society, I should
like to report the interesting work that I have been
doing, since last October, in Hongkong.

During the last two months, I have been treating
such diseases as elephantiasis, liver flukes, malaria,
all sorts of tropical skin diseases and intestinal
parasites, and plenty of pulmonary tuberculosis,
too.

Hongkong, a British crown colony, covers about
270 square miles of land and has 3,500,000 people
including 1,500,000 refugees from Red China.

I resigned my position at Iowa State University
to represent Promise, Inc., of Ames, in building a
medical clinic, a church, a school and a demonstra-
tion farm for these refugees — to take care of the
WHOLE MAN. The di’ugs, hybrid seeds, insecti-
cides, etc., paid for by Promise, Inc., have arrived
by the ton, and we have been able to start the
work. We hope to have the project fully operation-
al in a short time, but we already have two clinics
rendering medical service.

The morbidity report for the Colony, published
last week, may be of some interest to Iowa physi-
cians. They should keep in mind that 98 per cent
of the 3,500,000 are Chinese, and perhaps not more

HONGKONG HEALTH AND MEDICAL SERVICE
REPORT— WEEK ENDING JANUARY II, 1962

36 deaths from acute and infectious diseases
(including 27 from tuberculosis, I from
poliomyelitis and 3 from diphtheria)

Infectious Diseases Reported During the Week:

Disease

Cases

Pulmonary tuberculosis

(These were new cases. A total of 12,584 cases were
reported for the year 1961.)

Bacillary dysentery
Amebiasis
Typhoid fever

Poliomyelitis

Chicken pox

Diphtheria

Measles

Scarlet fever

Ophthalmia neonatorum
Malaria

306

4
38

2
I

5
19

Births Registered lor the Week:

Hongkong 588

Kowloon | 044

Kowloon new territories 258

Total 1,870

Deaths Registered for the Week:

Hongkong 90

Kowloon |74

Kowloon new territories 35

Total 299

than 10,000 are of other Asian nationalities or
Europeans. The climate is semi-tropical. There are
plenty of tropical and semi-tropical diseases. There
was a very severe cholera epidemic last summer.
Typhoid fever is endemic and so is dysentery.

From the above figures, one can readily believe
the reported death rate, but the figures for in-
fectious diseases are not reliable. There still are
two systems of medicine being practiced in Hong-
kong. The Western method is practiced by about
700 registered physicians from Great Britain, Can-
ada, Australia and other Western countries. Only
about 400 of them are in private practice; the rest
are in the service of the Hongkong government.

There are unknown numbers of Chinese herbists,
whom the government does not license. They can
treat patients in their own way, but may not per-
form surgery, give injections or dispense Western
poisonous drugs. Moreover, they cannot issue
death or birth certificates and may not report in-
fectious diseases. When they see cases of diph-
theria, for example, they cannot report them, but
can attempt to treat them until the patients die or
until a qualified man takes the cases. When one of
their patients dies, some sort of a death certificate
for him can be found in the “black market.” Thus,
not only the infectious disease rates but also the
statistics on causes of death are undependable.

We estimate that the total number of tubercu-
losis patients must have been as high as 250,000.
There aren’t enough beds for the tuberculosis pa-
tients, and they can’t be segregated. I have seen
several of them actually sleeping with scores of
other persons in the same flats.

Pak-Chue Chan, M.D.

The village in which Dr. Chan has located his first Hongkong
clinic unit.

116

The Search for Curable Hypertension

RAY W. GIFFORD, JR., M.D.*

CLUES TO THE CASES THAT ARE CURABLE

Cleveland, Ohio

In these days when we have potent and reasonably
effective antihypertensive drugs, I think we are
prone to disregard and forsake both the older diag-
nostic procedures and some of the newer technics
that are useful in establishing the cause for hyper-
tension.

Of course we are all aware that in most cases, in
spite of very thorough investigation, no cause can
be found. In such instances, we are justified in
utilizing “wastebasket” diagnoses. Examples of
these are “essential hypertension” or “idiopathic
hypertension,” neither of which means much. You
may have heard Dr. E. H. Rynearson, of the Mayo
Clinic, explain that “idiopathic” comes from the
Greek: idio — “I don’t know” and jpathic — “what
the hell it is.”

On the other hand, however, if we search for the
cause of hypertension in each instance, we find
that there are more and more cases for which
we can find causes. It is probably impossible to set
a percentage of patients for whose hypertension
there may be curable causes, but certainly it is in
the range of 5 to 10 per cent. And as we learn
more about diagnostic technics and more about
hypertension itself, I am sure we shall find more
and more potentially reversible cases.

Even though the curable types of hypertension
are rare and few, there are reasons for our spend-
ing some time searching for them. The medical
treatment for hypertension is still no more than
palliative, and it leaves a great deal to be desired,
for the side-effects are troublesome. Furthermore,
many patients do not adhere to the regimen faith-
fully, and it does no good if it isn’t followed.

* From the Department of Hypertension and Renal Dis-
eases, The Cleveland Clinic Foundation, Cleveland. Ohio. Dr.
Gifford was a member of the Staff in Internal Medicine at the
Mayo Clinic at the time he made this presentation at the 1960
Mercy Hospital Medical Day in Des Moines.

There are certain clues that suggest to us which
cases of hypertension may be secondary to dis-
coverable and curable causes. The first of these is
sudden onset of hypertension, or exacerbation of
pre-existing hypertension, especially if the family
history is negative. The second is occurrence in a
person less than 30 years of age, and particularly
in a child. Third is the early appearance of retinop-
athy of group III or group IV. By this I mean

SPECIFIC CAUSES
OF HYPERTENSION
TO BE RULED OUT

Coarctation of Aorta
Diagnostic feature:
absent or feeble fem-
oral pulsation

Pheochromocytoma
Diagnostic features:
often paroxysmal at-
tacks, metabolic ab-
normalities, positive
Regitine test

Cortical Hyperplasia or

Adenoma

1. Cushing's Syndrome

2. Primary Aldosteron-
ism

Diagnostic

features:

low serum potas-
sium, high CO-
combining power

Phelonephritis
Diagnostic features:
results of intravenous
pyelogram, urine cul-
tures, urinary sedi-
ment, etc.

Figure I. Some causes for secondary hypertension. (Cour-
tesy of Ciba Pharmaceutical Company.)

117

118

Journal oe Iowa Medical Society

March, 1962

the appearance of hemorrhages, exudates, and
papilledema in the optic fundus soon after the
onset of hypertension. Fourth is severe hyperten-
sive retinopathy, including marked arteriolar nar-
rowing with focal constrictions, hemorrhages and
exudates, but with little or no sclerosis of the reti-
nal arterioles.

The latter is simply a more elaborate way of say-
ing “hypertension of recent onset.” In many cases
the history with regard to onset of hypertension
may not be altogether clear. The patient may not
have had his blood pressure taken regularly. Thus,
minimal sclerosis in the retinal arterioles, or none
at all, is indirect evidence that the hypertension is
of recent onset. In spite of these clues, however,
many cases with curable causes may be overlooked
unless we become compulsive about routinely sub-
jecting hypertensive patients to certain laboratory
procedures.

Figure 1 lists some potentially curable causes for
hypertension: coarctation of the aorta, pheochro-
mocytoma, Cushing’s syndrome, primary aldoster-
onism, and unilateral renal parenchymal disease
such as pyelonephritis, tuberculosis, cysts, and
others. To those, we can add renal artery disease.
The latter did not appear in the drawing, although
it was made just a few years ago. This circum-
stance provides rather dramatic evidence that we
are still in the process of discovering curable
causes.

COARCTATION OF THE AORTA

The clinician should always palpate the femoral
pulses of hypertensive patients, but I fear that

Figure 2. Roentgenogram of the chest of patient with
coarctation of the aorta, demonstrating absence of aortic
knob and notching of inferior edges of ribs due to dilated,
tortuous intercostal arteries.

many of us have been surprised on at least one
occasion by an x-ray report containing the diag-
nosis “coarctation of the aorta” (Figures 2 and 3).
Such a patient has a reduction of blood pressure
and amplitude of arterial pulsations in the lower
extremities, and hypertension in the upper ex-
tremities, but one can miss the diagnosis unless he
makes a habit of feeling the femoral pulses. This
oversight occurs in examinations not only of chil-
dren but of adults as well. Moreover, it can be
missed repeatedly, for patients present themselves
as adults without any doctor’s having previously
suspected the diagnosis.

When coarctation occurs in the usual site (Fig-
ure 4), there is diminution or absence of pulses in
the lower extremities, and there is hypertension,
usually not severe, in the upper extremities. If the
coarctation is at the take-off of the subclavian artery
on the left, there will be hypotension and either
impalpable or reduced pulses in the left arm as
well as in the lower extremities. In some cases
there is an anomaly of the aortic arch so that the
right subclavian artery takes off distal to the co-
arctation. In that event, there is low blood pressure
and diminution or absence of pulses in the right
arm. In other cases, the ductus arteriosus may
remain patent distal to the coarctation, and then
if there is reversal of flow, there will be cyanosis
confined to the lower part of the body.

Figure 3. Roentgenogram of chest, demonstrating notching
of ribs in case of coarctation of thoracic aorta.

Vol. LII, No. 3

Journal of Iowa Medical Society

119

Because there are bruits over collateral and di-
lated intercostal arteries (Figure 5), and because
a systolic murmur may arise from the coarcted
area, some patients have had the erroneous diag-
nosis of rheumatic heart disease. Therefore, when
a young person with hypertension gives a history
of a “rheumatic heart” or of a heart murmur, one
must suspect that the difficulty has, instead, been a
coarctation. It must be remembered that some pa-
tients with coarctation also have a bicuspid aortic
valve, and there may be a regurgitant murmur due
to that anomaly.

The treatment, of course, is to resect the coarcted
area. Figure 2 shows lack of the usual prominence
of the aortic knob and notching of the ribs. As I
have said, the diagnosis should be made before the
patient goes to x-ray, but unfortunately it often
isn’t. Figure 3 is a close-up showing the notching
of the inferior aspect of the ribs due to the dilated,
tortuous intercostal arteries that act as collateral
vessels to carry blood around the coarcted area to
the aorta (Figure 5).

PHEOCHROMOCYTOMA

Pheochromocytomas are chromaffin tissue tu-
mors which usually arise from the adrenal medulla
and produce epinephrine or norepinephrine, or
both, and thereby cause hypertension. About 50
per cent of these tumors, for some reason or other,
function only intermittently and thus produce the
distinct clinical picture of paroxysmal hyperten-
sion, with all of the associated dramatic signs and
symptoms. In 26 cases of paroxysmal hypertension
due to pheochromocytoma, we have observed the
symptoms enumerated in Table 1. Most of these
patients have severe headaches, and it can be doc-

Fig. 4. Coarctation of thoracic aorta distal to left sub-
clavian artery.

umented that they have hypertension if the blood
pressure is taken during the headaches. Usually
this is a significant hypertension, often ranging
between 240/130 and 300/190 mm. Hg.

TABLE I

PRESENTING COMPLAINTS IN 26 CASES OF
PAROXYSMAL HYPERTENSION DUE TO
PHEOCHROMOCYTOMA

Severe headache

Tremor

Palpitation

Sweating

Pallor

Vertigo

Anxiety

Weakness

Pain in chest, back, hip
or leg, epigastrium
Nervousness
Nausea and vomiting

People who are vascular hyperreactors and have
migraine headaches will often have some increase
in blood pressure during their headaches, by vir-
tue of the stimulus of the pain. But it usually isn’t
as marked and dramatic as is the rise seen with
pheochromocytoma. When the full syndrome is in
evidence, it is very dramatic indeed. Pain in the
chest is frequent; it may be angina or a pain re-
sembling angina. During an attack, the patients
usually sweat profusely and have a rather marked
tremor. These patients, of course, are not truly
hypertensive, and are not likely to give us trouble
insofar as the diagnosis of sustained hypertension

Figure 5. Coarctation of aorta with diagrammatic repre-
sentation of collateral circulation. (From Allen, E. V., Barker,
N. W., and Hines, E. A. Jr.: Peripheral Vascular Diseases.
Second Edition. Philadelphia, W. B. Saunders Co., 1955,
p. 311.)

120

Journal of Iowa Medical Society

March, 1962

is concerned, for between attacks their blood pres-
sure is perfectly normal.

Table 2 contains data on paroxysmal hyperten-
sion due to pheochromocytoma. The basal meta-
bolic rate is usually normal when the tumor func-
tions paroxysmally. The blood sugar is usually
within normal range, although in 11 of 25 cases
there was elevation above 120 mg./lOO ml., by the
Folin Wu method. There are no striking changes
in the retinal arterioles. Some arteriolar narrowing
may occur, and occasionally there is some sclerosis,
but often the optic fundus is normal, for the pa-
tients are hypertensive only for a very insignificant
portion of the time.

TABLE 2

PAROXYSMAL HYPERTENSION: PERTINENT DATA—

12 MALE AND 14 FEMALE PATIENTS WITH
PHEOCHROMOCYTOMA

Range

Average

Age in years

. 26-59

Weight in pounds

106-192

134.4

Height in inches

62-72

Cases

B.M.R. %

< - 10

~ 1 0 to + 1 0

+ 1 1 to +20

> +20

Blood Sugar in mg./lOO cc. (Folin Wu)

<80

80 to 120

>120

1 1

Optic Fundus (Keith-Wagener)

Normal . . . .

Group 1

Group II

Retinal hemorrhage

The diagnosis of paroxysmally functioning pheo-
chromocytoma depends largely upon precipitating
an attack by injecting histamine. It is important
that the patient should not receive sedatives for
several days before the test, and it is also impor-
tant that an adequate basal blood pressure be
established before the histamine is given. Hista-
mine usually induces the paroxysm of severe hy-
pertension (Figure 6), along with the symptoms
which the patient experiences from spontaneous
attacks. It is also important to do a cold pressor
test either before or after the histamine test, in
order to have some measure of the patient’s vascu-
lar hyperreactivity. If putting the patient’s hand in
cold water will make his blood pressure rise as
high as histamine does, one is probably dealing
with a manifestation of vascular hyperreactivity,
and not a paroxysmally functioning tumor.

The determination of catecholamines in urine or

blood is not a completely satisfactory test for
paroxysmally functioning pheochromocytoma. Ob-
viously, if the urine is collected at a time when the
tumor is not functioning, one isn’t likely to find an
excess of catecholamines. The same is true for
pressor amines in the blood. On the other hand, if
the blood or urine is collected at a time when the
tumor is functioning spontaneously or after it has
been stimulated by histamine, an elevation of
catecholamines will then be found. This is another
way of distinguishing pheochromocytoma from
simple vascular hyperreactivity.

The patients who are most troublesome from a
diagnostic standpoint are those in whom the hyper-
tension is sustained, apparently because the tumors
are functioning most of the time. As Table 3 indi-
cates, their symptoms are similar to those of pa-
tients with paroxysmal attacks. They have head-
aches that are severe and often occur paroxysmal-
ly, even though the hypertension is sustained. The
duration of the headache is usually shorter than
ordinary hypertensive headache, however. Along
with the headaches, they perspire, they have

Pheochromocytoma

Figure 6. Positive pharmacologic tests in a patient with
pheochromocytoma. Phentolamine (Regitine) caused signifi-
cant decrease in blood pressure, and histamine caused pressor
response, significantly greater than that during the cold
pressor test. (From Gifford, R. W. Jr., Roth, G. M., and
Kvale, W. F.: Evaluation of a new adrenolytic drug (Regitine)
as a test for pheochromocytoma. J.A.M.A. 149:1628, (August
30) 1952.)

Vol. LII, No. 3

Journal of Iowa Medical Society

121

TABLE 3

PRESENTING COMPLAINTS IN CASES OF PERSISTENT
HYPERTENSION DUE TO PHEOCHROMOCYTOMA

Attacks similar to those in paroxysmal hypertension:
Headaches
Perspiration
Nervousness
Palpitation
Tremor
Loss of weight
Hypertension

tremor, they are extremely nervous and agitated,
and they usually give histories of weight loss.
These symptoms also suggest hyperthyroidism,
and this too must be ruled out.

Patients who have pheochromocytomas that
function more or less continuously are usually thin.
As a matter of fact, we almost automatically rule
out pheochromocytoma as the cause for sustained
hypertension in an obese patient. The data on
these patients are summarized in Table 4.

The basal metabolic rate is likely to be elevated,
sometimes to rather dramatic levels. The highest
basal metabolic rates ever recorded at the Mayo
Clinic have been in patients with continuously
functioning pheochromocytomas. These individuals
also tend to have elevations of the blood sugar,
and findings in the optic fundi indicate rather
severe hypertension. Some of them actually have
papilledema. When one encounters the triad of

Pheochromocytoma

Figure 7. Positive response to phentolamine (Regitine)
given intravenously, and falsely negative response to phen-
tolamine given intramuscularly in patient with pheochromocy-
toma. The overshoot which followed the depressor response
to the intravenous test is unusual. Piperoxan (Benodaine) also
caused a positive depressor response, confirming the intra-
venous Regitine test. (From Gifford, R. W. Jr., Roth, G. M.,
and Kvale, W. F.: Evaluation of a new adrenolytic drug
(Regitine) as a test for pheochromocytoma. J.A.M.A.
149:1628, (August 30) 1952.)

TABLE 4

PERSISTENT HYPERTENSION: PERTINENT DATA—
13 MALE AND I I FEMALE PATIENTS WITH
PHEOCHROMOCYTOMA

Range

Average

Age in years

12-67

35.6

Height in inch

61-70

65.2

Weight in pou

nds

90- 1 69

121.8

Cases

B.M.R. %

< +10

+ 1 1 to

+ 20

+ 21 to

+ 101

Blood sugar in

mg./lOO cc. (Folin Wu)

80 to 120

120 to 256

Not done

Optic Fundus 1

( Keith-Wagener)

Normal . .

Group 1

Group II

Group III

Group IV

H’s: hyperglycemia, hypertension, and hyperme-
tabolism without hyperthyroidism, one should sus-
pect pheochromocytoma.

The pharmacologic test for pheochromocytoma
that functions persistently entails the use of a drug
that will neutralize the effects of the pressor sub-
stance and rapidly bring the blood pressure down.
Such a substance is phentolamine (Regitine). Posi-
tive responses are recorded in Figures 6 and 7, the
blood pressure falling promptly to normotensive
levels following the administration of 5 mg. of this
agent. When given intramuscularly, Regitine may
produce a falsely negative result (Figure 7), and
for this reason we insist upon its being given intra-
venously. Piperoxan (Benodaine) can be used as
a confirmatory test, for like Regitine it neutralizes
the effect of circulating epinephrine and norepi-
nephrine (Figure 7). But in patients with essential
hypertension Piperoxan sometimes produces a fur-
ther rise in blood pressure, along with palpitation,
tachycardia, flushing, and general discomfort (Fig-
ure 8). Indeed this drug may sometimes precipi-
tate angina pectoris in patients with preexisting
coronary disease, whereas Regitine, when given to
patients with essential hypertension, exerts no
pressor effect and causes none of the other side re-
actions. Regitine is the drug of choice for patients
whose initial blood pressure is above 180/120 mm
Hg. Histamine should not be given to such patients,
for it may result in a dangerous pressor response.

Patients who have sustained hypertension be-
cause of continuously functioning pheochromocy-
toma will have elevated values for urinary cate-
cholamines and for blood pressor amines. As a

122

Journal of Iowa Medical Society

March, 1962

matter of fact, we have more or less come to rely
upon these as screening procedures to rule out
persistently functioning pheochromocytoma. Only
for patients in whom we strongly suspect pheo-
chromocytoma on a clinical basis do we also order
the pharmacologic tests.

TABLE 5

INDICATIONS FOR TESTS FOR PHEOCHROMOCYTOMA

1. Spells of headache, sweating or tremor.

2. History of fluctuating blood pressure.

3. Hypertension in a young patient.

4. Hypermetabolism without hyperthyroidism.

5. Hype rtension in a thin patient or one who has been losing
weight.

6. Short history of hypertension.

7. Severe hypertension, group 2, 3 or 4, fitting any of the
above categories.

8. Paradoxical response to the ganglionic blocking agents.

9. U nsatisfactory response to an anesthetic, with a rise in
blood pressure.

Routine tests for pheochromocytoma, either
pharmacologic or chemical, need not be carried
out for every hypertensive patient (Table 5).
When hypertension is severe; when it is accom-
panied by paroxysmal headache and profuse dia-
phoresis; when the patient is a young person; when
the disease is of recent origin; or when it is accom-
panied by diabetes or hypermetabolism, one or
both tests should be made to rule out pheochromo-
cytoma. Also, patients whose blood pressures re-
spond paradoxically to ganglion-blocking agents, or
who react unsatisfactorily to induction of anes-
thesia (i.e., with a rise in blood pressure) should
be suspected of having such a tumor. The diagnosis
is sometimes made when a patient who is about
to be operated upon for some other reason mani-
fests a tremendous pressor response during the in-
duction of anesthesia. Conversely, when an indi-
vidual about to be operated upon for pheochromo-
cytoma fails to show a rise in blood pressure dur-
ing induction of anesthesia, I am always fearful
that I may have missed the diagnosis (and some-
times this is the case!) .

Figure 8. Pressor response to intravenous administration of Piperoxan is contrasted to the lack of any significant change in
blood pressure when Regitine is given intravenously to two patients with essential hypertension. (From Gifford, R. W. Jr.,
Roth, G. M., and Kvale, W. F.: Evaluation of a new adrenolytic drug (Regitine) as a test for pheochromocytoma. J.A.M.A.
149:1628, (August 30) 1952.)

Vol. LII, No. 3

Journal of Iowa Medical Society

123

For the removal of pheochromocytomas, Mayo
Clinic and Cleveland Clinic surgeons prefer an an-
terior approach for three reasons. First, preopera-
tive localization is unnecessary. Second, ectopically
located pheochromocytomas can be found. Third,
bilateral tumors can be removed. The tumors can
occur along the aorta, at the bifurcation of that
vessel, or behind the right lobe of the liver. It is
important that Regitine be given to the patient to
combat hypertensive crises during induction of
anesthesia and during manipulation of the tumor.
Usually it is necessary that the patient receive a
pressor agent during the first several hours post-
operatively, for the blood pressure tends to drop
dramatically to shock levels after the tumor has
been removed.

CUSHING'S SYNDROME

I am sure that the patient shown in Figure 9 will
be recognized as having Cushing’s syndrome.
About 90 per cent of patients who have Cushing’s
syndrome also have hypertension, and hyperten-
sion is sometimes the presenting complaint. There
is no way of making a diagnosis of Cushing’s syn-
drome without first suspecting it, and then making
the necessary tests. And there is no way of sus-
pecting it without recognizing the characteristic
appearance of such individuals. The “moon face”
isn’t the only sign. The so-called “buffalo” or trun-
cal obesity is evident in the patient shown in Fig-
ure 10, and the striae are especially distinct on the

Figure 9. Typical facies of Cushing's syndrome. (From
Sprague, R. G., Randall, R. V., Salassa, R. M., Scholz, D. A.,
Priestley, J. T., Walters, W., and Bulbulian, A. H.: Cushing's
Syndrome. Arch. Int. Med. 98:389, (September) 1956.)

abdomen of the man shown in Figure 11, although
the “moon face” is less pronounced in his case.

Figure 10. Body habitus in Cushing's syndrome. Truncal
obesity is characteristic. (From Sprague, R. G., Randall,
R. V., Salassa, R. M., Scholz, D. A., Priestley, J. T., Wal-
ters, W., and Bulbulian, A. H.: Cushing's Syndrome. Arch.
Int. Med. 98:389, (September) 1956.)

Figure II. Abdominal striae in Cushing’s syndrome. (Cour-
tesy of Dr. R. M. Salassa, Mayo Clinic, Rochester, Minn.)

124

Journal of Iowa Medical Society

March, 1962

The lady shown in Figure 12 has the cervico-dorsal
hump that is typical of the syndrome.

Figure 13 shows four pictures of the same young
man. When he came to the Mayo Clinic, he had
the appearance shown at the lower left. Upon
questioning, he admitted that his appearance and
body habitus had changed recently, and upon re-
quest he produced old photographs to confirm this.
The picture at the upper left in the figure had been
taken two years before, and the one at the upper
right one year before he was first seen. The pic-
ture at the lower right was taken six months after
subtotal resection of his adrenal glands.

Thus, it is important to question patients about
changes that may have occurred in their appear-
ances. Some individuals always have had faces
and bodily contours suggestive of Cushing’s syn-
drome, but others have acquired such character-
istics, and it is only the latter in whom the signs
are pathognomonic.

Patients with Cushing’s syndrome are usually
women, and they usually have increased body and
facial hair. Hirsutism is another characteristic
about which hypertensive patients should be ques-
tioned. One should ask such women whether they
have always had hair on their faces, or whether it
is a recent development.

Table 6 contains a list of the clinical manifesta-
tions of Cushing’s syndrome, and the frequency
with which each was noted in 100 patients seen
at the Mayo Clinic. The hypertension may be mild

Figure 12. Cervico-dorsal hump in Cushing's syndrome.
(Courtesy of Dr. R. M. Salassa, Mayo Clinic, Rochester,
Minn.)

or severe, and resembles essential hypertension
except for the fact that other features of Cushing’s
syndrome listed in Table 6 appear in conjunction
with it.

TABLE 6

CLINICAL SIGNS AND SYMPTOMS OF CUSHING'S
SYNDROME, 100 CASES*

Rounding of the face 92

Hypertension >150/90 mm. Hg. 90

Truncal obesity 84

Plethora of the face 81

Hirsutism-!' 74

Cervicodorsal hump 67

Purple striae 64

Acne and keratosis pilaris 64

Ecchymoses 62

Amenorrheat 35

* Sprague, R. G., Randall, R. V., Salassa, R. M., Scholz,
D. A., Priestley, J. T., Walters, W. and Bulbulian, A. H.:
Cushing’s Syndrome. Arch. Int. Med. 98:389 (September)
1956.

t There were 81 females including one child.

t There were 63 females between 29 and 45 years of age.

The laboratory findings in 100 patients are
shown in Table 7. The clincher, of course, is the
finding of increased amounts of corticosteroids in
the urine, or elevated levels of plasma corticoids.
Removal of the adrenal cortical tumor, or in the
absence of a tumor, resection of the adrenal
glands, either subtotally or totally, usually leads to

Figure 13. Cushing's syndrome — "before and after." See
text. (Courtesy of Dr. R. M. Salassa, Mayo Clinic, Rochester,
Minn.)

Vol. LII, No. 3

Journal of Iowa Medical Society

125

TABLE 7

LABORATORY FINDINGS IN CUSHING'S SYNDROME,
100 CASES*

Lymphopenia 81

Hyperglycemia* 57

Alkaline urine . . . . 37

Hypopotassemia 35

Alkalosis 26

Hypochloremia 15

Polycythemia . 12

Hypernatremia . 5

* Sprague, R. G., Randall, R. V., Salassa, R. M., Scholz,
D. A., Priestley, J. T., Walters, W. and Bulbulian, A. H.:
Cushing’s Syndrome. Arch. Int. Med. 98:389 (September)
1956.

t Data obtained from 67 cases in which carbohydrate metab-
olism was adequately studied.

reversal of all the characteristics of the syndrome,
including the hypertension.

PRIMARY ALDOSTERONISM

Primary aldosteronism, first described by Conn
at the University of Michigan, masquerades as es-
sential hypertension, and often one does not sus-
pect it on the basis of historical data alone. The
clinical symptoms and signs, and the laboratory
findings are summarized in Table 8. A history of
headaches, polyuria, polydipsia, episodic muscular
weakness, and intermittent tetany should arouse
suspicion of primary aldosteronism. The muscular
weakness is a dramatic symptom, if present, but it
usually isn’t. The headache is not characteristic.
All the cases that have been reported have had
hypertension. Some patients have had positive

TABLE 8

PRIMARY ALDOSTERONISM

Symptoms

Physical Signs

Laboratory Findings

Headache

Hypertension

Hypokalemia

Polyuria and
polydipsia

Positive Chvostek
and Trousseau

Hyperaldosteronuria

Episodic muscular
weakness

Low specific gracity of
urine

Intermittent tetany

Neutral or alkaline

urine
Alkalosis
EKG changes of
hypokalemia
Hypernatremia
High U/P ratio for
potassium at low
levels of serum K

Chvostek and Trousseau signs, but these findings
are not usual.

The most important laboratory finding is hypo-
kalemia. I know of no better or more practical way
to screen patients for this syndrome than to de-
termine the serum potassium routinely in all cases
of hypertension. It is impractical to determine the
aldosterone in the urine on a routine basis, for the
test is complicated and time-consuming, and be-
sides it is not specific, for there are other causes
for increased levels of aldosterone in the urine,
namely, congestive heart failure, cirrhosis of the

Figure 14. Electrocardiographic changes of hypokalemia with reversion towards normal after administration of potassium intra-
venously. (Courtesy of Dr. H. B. Burchell, Mayo Clinic, Rochester, Minn.)

126

Journal of Iowa Medical Society

March, 1962

liver, nephrotic syndrome, low sodium diet, and
others.

Patients with this syndrome characteristically
have a low specific gravity of the urine and a neu-
tral or alkaline urine. It is more informative to
perform a urine concentration test than to depend
upon a random sample for specific gravity. Urine
that has been stored in the laboratory for any
length of time may have turned alkaline before
analysis.

Electrocardiographers will tell us that the elec-
trocardiogram is all we need to tip us off that the
serum potassium is low. I suppose that if one is an
expert in interpreting such tracings, this is correct,
but since I am not an expert, I order serum potas-
sium. Figure 14 is a characteristic tracing reflect-
ing hypokalemia. The undulating S-T segment
merges into an ill-defined T wave, and there is a
prominent U-wave. After potassium chloride has
been given intravenously, the T-waves are much
more prominent and the U-waves less so.

A very marked pattern of hypokalemia is shown
in Figure 15. This patient had primary aldosteron-
ism. When the serum potassium rose to 3.4 mEq/L.
following the administration of a potassium salt,
there was a marked change in the configuration of
the T-waves and U-waves. When the serum potas-
sium fell to 2.5 mEq/L., the electrocardiogram did
not revert to the former pattern. This probably
has something to do with the ratio of intracellular
potassium to serum potassium. For this reason, I
am unwilling to accept a normal electrocardiogram
as conclusive evidence against primary aldosteron-
ism.

Figure 15. Electrocardiographic changes of hypokalemia in
a patient with primary aldosteronism. (From Weaver, W. F.,
Salassa, R. M., and Burchell, H. B.: An evaluation of the
electrocardiogram and the acidity of the urine as a screen-
ing test for primary aldosteronism. Am. J. Med. Sci. 238:162,
(August) 1959.)

Figure 16 is a summary of observations made on
a woman who has been seen periodically at the
Mayo Clinic since 1942. She gradually became
hypertensive about 1953. At approximately the
same time, her urine began to give an alkaline re-
action. It also became dilute (these were random
specimens). The blood pressure elevation gradu-
ally became more marked. In retrospect the elec-
trocardiogram suggested hypokalemia in 1954. It
wasn’t until Conn made his pronouncement in
1955 that we discovered that this woman had per-
sistent hypokalemia. She had a little elevation of
the plasma carbon dioxide, but not a very marked
one, and it often isn’t. In 1957, an adrenocortical
adenoma was removed. We have now observed 13
such cases. Most were discovered by measuring
serum potassium in hypertensive patients. I should
point out, however, that by far the commonest
cause for hypokalemia in hypertensive patients is
therapy with one of the thiazide diuretics, and the
serum potassium level may remain low for several
days or even weeks after the discontinuing of such
therapy.

Adrenal cortical adenomas are usually responsi-
ble for this disease, although in some young pa-
tients only hyperplasia has been found.

UNILATERAL DISEASE OF RENAL PARENCHYMA

A fairly common cause for secondary hyperten-
sion that is amenable to surgical cure is unilateral
renal disease. The excretory urogram of one of
the first cases described by Dr. N. W. Barker in
his work on atrophic pyelonephritis as a cause
for hypertension, back in 1939, is shown in Figure
17. This shows a contracted right kidney with a
stone in it and compensatory hypertrophy of the
left kidney. The right kidney, which weighed 40
Gm., was removed, and the patient has been nor-
motensive ever since. There was no suggestive
history of renal disease in this case. Because of

34-YEAR-OLD WOMAN (1942)

Year

Blood
pressure,
mm. Hg

Urinalysis

Plasma

Hypokalemia
on ECG

Re-

action

Sp.

grav.

Serum K,
mEq./L.

C02,

mEq./L.

Urea,

mg/100 ml.

1942

140/88

Acid

1 030

1949

140/90

Acid

1.036

1951

155/90

Acid

1.030

—

1953

190/100

Acid

1.020

—

1954

192/100

Aik.

1.018

Suggestive

1955

190/100 '

Aik.

1.010

3.2

Supportive

1.006

2.8

—

1956

195/110

Aik.

1.005

Aik.

1.006

Character-

istic

1957

210/120

Aik.

1.011

3.1

Aik.

1.010

3.2

11/25/57: Operation— removal of adrenal cortical adenoma

1958 1 140/85 | Acid | 1.008 | 4.9 | 25 | 44 | Normal

Figure 16. A case of primary aldosteronism. (From Weaver,
W. F., Salassa, R. M., and Burchell, H. B.: An evaluation of
the electrocardiogram and the acidity of the urine as a
screening test for primary aldosteronism. Am. J. Med. Sci.
238:162, (August) 1959.)

Vol. LII, No. 3

Journal of Iowa Medical Society

127

TABLE 9

POSTOPERATIVE RESULTS IN 61 HYPERTENSIVE PATIENTS
WHO UNDERWENT UNILATERAL NEPHRECTOMY

Time After Operation

Immediately Two Years Five Years

Result (Two to Four Weeks) Plus Plus*

Good 31 25 10

Fair . . 13 10 5

Poor . 17 20 II

Death 0 6 6

Total 61 61 32

* Figures in this colum are based on 32 traced patients.

this and many similar observations since, we now
advocate routine excretory urograms as part of
the work-up for hypertensive patients.

Dr. Barker reviewed his series about 10 years
ago, and found that 61 hypertensive patients had
undergone unilateral nephrectomy, mostly for
atrophic pyelonephritis. The results are summa-
rized in Table 9. In the immediate postoperative
period, 50 per cent had “good” results, which
means that they were normotensive. After five
years, only 30 per cent remained normotensive.
The longer such a group is followed, the more
individuals are found once again to be hyperten-
sive, but even a five year respite from severe hy-
pertension is worthwhile.

RENAL ARTERY DISEASE

Probably the commonest cause for remediable
hypertension recognized today is disease of one or

Figure 17. Excretory urogram showing atrophy of right
kidney and compensatory hypertrophy of left kidney. Hyper-
tension was cured by right nephrectomy. (Courtesy of Dr.
N. W. Barker, Rochester, Minn.)

both renal arteries or their branches. Figure 18 is
a translumbar aortogram of a young hypertensive
patient showing no opacification of the left main
renal artery, but normal circulation to the right
kidney. Removal of the left kidney brought about
a reversal of hypertension, and the patient has
been normotensive ever since. Whenever possible,
of course, it is preferable to perform reconstructive
arterial surgery and thereby preserve the ischemic
kidney.

Renal angiography is indicated whenever a dis-
crepancy in size or function between the two kid-
neys is demonstrated on excretory urograms. Un-
fortunately excretory urograms won’t always give
a clue to the presence of renal artery disease. If
excretory urograms are normal, renal angiography
is indicated when hypertension is of recent onset
or when there has been recent exacerbation of
chronic hypertension. It is also indicated for most
hypertensive patients less than 35 years of age,
and for patients with malignant hypertension re-
gardless of age and duration of hypertension. This
important cause for curable hypertension will be
considered in more detail in the panel discussion
that follows.

SUMMARY

I have attempted to present some of the diag-
nostic methods by which it is possible to ferret out
those few cases of hypertension that are amenable
to surgical cure. In most cases a surgical procedure
is preferable to medical palliation.

Figure 18. Translumbar aortogram showing non-opacifica-
tion of left renal artery in patient with hypertension.

Panel Discussion

The Treatment of Hypertension

Question: Do you ever get “false-positive” cate-
cholamines?

Paul From, M.D., Des Moines internist: “False-
positive” catecholamine reports have occurred.
The usual reason has been that the patient ate
bananas within two or three days prior to the
taking of urine for study. Otherwise, I don’t know
of any chemical causes for the phenomenon. Of
course one sometimes sees slight rises of the uri-
nary catecholamines — that is, rises above normal
but not to the possibly ten-fold level that is usually
regarded as within the diagnostic range for pheo-
chromocytoma.

Question: Do metastases from a bronchogenic
carcinoma to the adrenals ever produce “false-
positive” catecholamines?

Dr. Gifford: No. Have you seen such a case?

Questioner : Yes, I have seen several within the
past six months.

Dr. Gifford: “False-positives” are seen rather
frequently. We use a fluorometric method adapted
from Von Euhler, and some antibiotics, among
other things, interfere with it. If the patient is
taking nose drops, perhaps for the side effects of
rauwolfia, the pressor amines and catecholamines
are elevated, and we have found that jaundice
will cause “false positive” catecholamines in some
patients. But we think that “false positives,” gen-
erally, represent fluorometric errors.

Dr. From: At the Mayo Clinic, in screening
hypertensive patients, at what level above normal
is it thought that further investigation of pheo-
chromocytoma is indicated?

Dr. Gifford: You have asked about a technical
detail that I lack information on. Dr. Maher has
worked out a qualitative test, and the clinicians
get either a positive or a negative report from
him. When the report is positive, the readings
have been in excess of twice what are regarded as
the upper limit of normal. We have been fooled
sometimes, but ordinarily we feel that pheochro-
mocytoma patients have a three- or four-fold in-
crease over normal.

DIAGNOSING OCCLUSION OF THE RENAL ARTERY

I should like to ask Dr. Fatland what he thinks
is the best procedure for diagnosing occlusion of
the renal artery.

John L. Fatland, M.D., Des Moines urologist: In-
vestigation of the urinary tract offers many possi-

bilities, and I think it behooves us to use as many
of them as are necessary, trying the simplest and
least formidable first. Occlusion or partial occlu-
sion of the renal arterial tree can occur with-
out remarkable changes in function, perhaps be-
cause of collateral circulation. On the other hand,
I think that careful scrutiny perhaps will reveal
clues that might be missed on a cursory examina-
tion of the intravenous urogram. Certainly one
should use the intravenous urogram, but I don’t
know in what order to put the others.

On the West Coast, Winter and Goodwin have
provoked some interest in the radioactive Diodrast
roentgenogram. Just how much value it has, we
really don’t know at the moment. It’s not a formi-
dable procedure, however, and it may help to de-
termine the vascular structure and integrity of the
kidney. Next, there is retrograde pyelography. I
think that we have had more experience with it.
Then there are the estimation of renal function by
sodium excretion, which has been described by
Howard, and the procedures employing phenol-
sulfonphthalein and certain other elements.

About 20 years ago, Dr. Flocks wrote an ex-
cellent article reporting on the estimation of renal
function and its relationship to renal mass suggest-
ing the presence of renal ischemia.

Retrograde pyelography isn’t fraught with the
morbidity and dangers of arteriography, and it is
probably the best procedure for actually visualiz-
ing the size and configuration of the kidney.

Dr. Gifford: If you had a patient in whom the
radioisotope nephrogram showed definite diminu-
tion of the flow to one kidney but normal flow to
the other, and in whom the Howard test was posi-
tive by your criteria — and I haven’t asked you
what your criteria are — would you be willing to
operate without first getting an aortogram?

Dr. Fatland: I think I’d like to have an aorto-
gram.

Dr. Gifford: Do you think that there cases in
which it appears from the aortogram that the cir-
culation is normal, but in which the Howard test
or a radioisotope nephrogram might show some
disparity in renal function?

Dr. Fatland: I think so. I think that there are
documented cases of the loss of an accessory ves-
sel to one pole of the kidney sufficient to produce
enough ischemia for hypertension.

128

Vol. LII, No. 3

Journal of Iowa Medical Society

129

Dr. Gifford: That’s right. From what we can see
in the aortogram, we can call it normal, yet there
can be ischemia due to occlusion of a collateral
vessel or an accessory renal vessel that is produc-
ing hypertension.

Do you think that every hypertensive patient
should have an investigation along these lines to
rule out occlusion of the renal artery or an ac-
cessory renal artery?

Dr. Fatland: No, I should think it impracticable.
As you have said, I think that patients in whom
hypertension has occurred suddenly — certainly
young people with hypertension— are deserving of
renal-tract evaluation.

Dr. Gifford: Even if the excretory urogram is
completely normal, you feel that any of these
young patients or the ones who have experienced
recent onset and have no family histories of hyper-
tension should be investigated further?

Dr. Fatland: I certainly think so.

I’d like to bring up another diagnostic consider-
ation, if I may. One often can get a tip-off regard-
ing a renal artery abnormality, especially an
aneurysm or a thrombosis that isn’t completely oc-
cluding blood flow, simply by placing a stethoscope
about the renal area both posteriorly and anterior-
ly and listening for bruits. If any are heard, then
the aortogram is the next step to take in the diag-
nosis.

Dr. Gifford: I’m glad you brought that up. We
have found that bruits are sometimes very promi-
nent. Of course one doesn’t hear them unless he
listens for them routinely. On the other hand, how-
ever, the absence of bruits certainly doesn’t rule
out an occlusion of a renal artery.

In your experience, is 75 per cent a high figure
for occlusion of a renal artery as the cause of
hypertension?

Dr. Fatland: I can’t answer that question from
my own experience, but I can relate some figures
from the literature. At the Cleveland Clinic, in a
review of 337 hypertensive patients on whom aor-
tography had been done, Poutasse reports that
93 had suggestions of kidney vascular system oc-
clusion. Yes, though I don’t know what criteria
the Cleveland doctors used in doing aortograms
on their patients, I’d say that 75 per cent is a
rather high figure.

Dr. Gifford: I’d say that the Cleveland findings
reflect about a 25 per cent incidence, and I’m
sure that the criteria employed were similar to
those that I have outlined. Dr. Poutasse says that
any discrepancy in the pole-to-pole length of the
kidneys greater than 0.5 cm. is significant, and he
does an aortogram.

Rubin F. Flocks, M.D., professor and head of
urology, SUI: Some years ago, we studied a group
of youngsters with sudden onsets of hypertension,
without histories and without any appearance of
malignant fundus. We found that only a little over
two per cent had renal disease probably underly-
ing their hypertension. When we culled out those
having the criteria that you have listed, Dr. Gif-

ford, they constituted approximately 25 per cent of
the group.

Our procedure consisted essentially of the tech-
nic that the panel has suggested here today — a
plane film, an intravenous pyelogram. With regard
to the intravenous, I might say that it is a good
idea to take the first film in about three minutes
and the second one in about five minutes after the
injection of the dye, and to study them rather than
the later ones. The later films may seem perfectly
normal — that is, the same on both sides — but the
earlier ones will give one an idea of the rapidity
with which the blood is entering the kidney. Thus,
for example, the first film may show good visuali-
zation on the right side and poor on the left, indi-
cating that some lesion of the renal artery is im-
peding blood flow to the left kidney, though on
a film taken 10 minutes later, when the kidney
pelvis has filled up, both sides appear normal.

In 1939 we started a comparative study of segre-
gated renal functions and pyelograms in 23 such
patients. By means of bilateral ureteral catheteri-
zation, we were able to predict the presence or
absence of hypertension and to decide upon uni-
lateral nephrectomy by utilizing the relationships
between renal mass and PSP-excretion over a
15-minute period. Howard later developed a simi-
lar test, and it has become very popular. It utilizes
the volumes of urine and sodium excretion in the
same way. Most of these tests are subject to error,
however, in that there is leakage around the ure-
thral catheters, and there are also some errors in
the chemical laboratories so that the total pic-
ture must be considered before one decides upon
nephrectomy or renal artery exploration in an
effort to determine the cause of hypertension.

One of my associates, Dr. Culp, has been par-
ticularly interested in the radioactive renogram
pioneered by Winter for the study of patients with
hypertension. He has studied well over 150 such
individuals and has been able to utilize the tech-
nic in conjunction with other methods for picking
out those in whom unilateral renal disease is, or
seems to be, the cause of hypertension. Our group
has been doing approximately five or six of them
a year, and we have been able to isolate a total of
five or six such patients with renal ischemia as
the primary cause of the hypertension. We utilize
the technic of Poutasse for renal arteriography,
and we have found that it spares us the compli-
cations of the older technics used by Clark, Smith
and others.

Dr. Gifford: I should like the panel’s opinions as
to whether a patient with a segmental occlusion of
one renal artery should have surgical correction
or should be treated medically.

Dr. From: If the patient actually has an occlu-
sion of the renal artery and does have hyperten-
sive disease, I feel that in the long run it would
be best to treat him surgically, if the occlusion
can be by-passed or repaired completely. His hy-
pertension could be taken care of medically for
a while, but there would be the possibility of side

130

Journal of Iowa Medical Society

March, 1962

effects and an actual added expense involved in
drug therapy. Thus I think that such a patient
should at least be explored in an effort to correct
the defect surgically.

Dr. Gifford: You prefer surgical management,
Dr. From, and I note that the other panel members
agree with you. Generally, I am an enthusiast for
medical management myself, but the results have
been good enough to date to warrant surgical cor-
rection of this type of lesion if it has been discov-
ered. Certainly there isn’t much point in looking
for it if one isn’t going to do anything about it.

ESTABLISHING THE DIAGNOSIS OF HYPERTENSION

Now, regarding the 90 per cent of hypertensive
patients in whom extensive studies such as these
fail to reveal a cause for their disease, and in
whom we must resort to medical therapy. I should
like to ask Dr. Schupp how he establishes that a
patient indeed has hypertension.

Joseph G. Schupp, Jr., M.D., Des Moines intern-
ist: Of course there is a difference between high
blood pressure and hypertension, and I think that
the way to establish the presence of hypertension
is to take blood pressures repeatedly. I feel that
anyone who has a pressure of 160/100 mm. Hg
consistently must be considered hypertensive.

Dr. Gifford: Just how many times would you
like to take his blood pressure, and over how long
a period?

Dr. Schupp: I don’t believe in having a patient
take his own blood pressure at home. Rather, I
want to take the readings myself, in the office.
If over a half-dozen determinations, separated by
rest periods in the office, the patient continues to
manifest pressures considerably above normal, I
consider him to be a hypertensive.

Dr. From: I feel that three random blood pres-
sures in excess of 160/90-100 mm. Hg are enough
to establish hypertension in a patient below 60
years of age. One other way to go about the
determination is to hospitalize the patient and let
a technician take the blood pressures, although it
has been said that the blood pressure may be high-
er when the doctor takes it than when a technician
takes it. If after 48 hours of hospitalization the
blood pressure level is still above 160/95 mm. Hg,
I think he can be said to have hypertension.

Dr. Gifford: I like those figures 160/90-100 mm.
Hg. They are the ones that I use. Certainly hyper-
tension has to be diagnosed carefully. So many
individuals — particularly young people — have ele-
vated readings the first time they meet the doctor
that several measurements are necessary. This
phenomenon I prefer to call vascular hyperre-
activity, and there is a question in my mind about
whether these patients need treatment at all.

TREATMENT OF THE ASYMPTOMATIC HYPERTENSIVE
PATIENT 45 YEARS OLD

Now let’s suppose that we have a patient who
does have hypertension. His blood pressure con-

sistently is 110 mm., or thereabouts, diastolic.
There is some narrowing and sclerosis of his ret-
inal arterioles, but there are no exudates or hem-
orrhages. His renal function seems normal. His
cardiac function seems normal. He has no symp-
toms. He is 45 years old. Would you treat him?

Dr. From: Yes, I would. Even though, in the
main, I’d be treating a blood pressure reading,
I’d do so, for one has to draw the line somewhere.
We know that he has a vascular disease because of
his hypertension, for there is some evidence of
an arteriosclerotic process going on within his
fundus.

Preferably within six months or a year, drug
therapy might possibly reverse some mechanism
so that his blood pressure would return to normal.
Whether I would go on treating him would de-
pend upon the particular findings in the case and
upon the patient’s emotional balance. First I
would certainly get his weight down to normal.
I would try to teach him the nature of the disease,
and I would try to treat the overlying anxiety that
many of these people have. Then, if I had been
successful, I would come down to the problem of
actually treating the hypertension.

Dr. Gifford: What drugs would you use?

Dr. From: I’d start with one of the diuretic
agents. They are relatively new, although we have
known for a long time that salt and hypertension
are rather intimately connected. Exactly what this
connection is, we are still not certain, but we know
that there is one. Some of the chlorothiazide or
hydrochlorothiazide derivatives, or benzydroflu-
methiazide (Naturetin), we know, must act some-
where in the region of the proximal tubule and
can cause an outpouring of sodium in these people.
It is true, especially with chlorothiazide or its de-
rivatives, that the concentration of chloride, or in
some cases the concentration of potassium, is
raised, but at least the sodium goes out. We know
that changes occur in the patients’ extracellular
volume, and that they respond much better in the
long run to these than to any other hypotensive
agent that can be added to their regimen. Thus, I
think that the best thing for us to do is to start
them on chlorothiazide or one of its derivatives.
Specifically, one can prescribe Diuril in a dose of
0.5 Gm. every 12 hours, or early in the morning
and late in the afternoon. Esidrix, which has a
greater potency in proportion to weight, can be
given in a dosage of 50 mg., and Naturetin can be
given in a dosage of 5 mg.

I would give one of these drugs a one week’s
trial, and in some cases this medication alone
might bring the patient’s blood pressure to an es-
sentially normal level. In the meantime, I’d have
treated his underlying anxiety with some mild
sedative such as Butapal or sodium amytal. If, at
the end of this one week, he needed further drug
therapy, I’d begin using one of the rauwolfia de-
rivatives. Giving reserpine twice daily for a couple
of weeks, and lowering the dosage as the blood

Vol. LII, No. 3

Journal of Iowa Medical Society

131

pressure fell, and then actually stopping the drug
after three or four months might bring an end to
the hypertension. If the combination of chloro-
thiazide and rauwolfia proved ineffective, I’d then
go to apresoline or hydralazine, adding this drug in
a step-by-step fashion up to a dosage of no more
than 300 mg./day. Some doctors may think this
dosage a little high, and it has been argued that
no more than 150 mg./day should be given, but I
have used apresoline a great number of times with-
out seeing the lupus erythematosus syndrome oc-
cur.

If after one or two months of this therapy (ac-
tually, I’d be doing this at practically two-week in-
tervals), I’d then go to one of the ganglionic block-
ing agents if this man still had hypertensive dis-
ease, and I’d prefer Inversine (mecamylamine hy-
drochloride). After six months or a year, if his
blood pressure had fallen and was holding fairly
well at normotensive levels, I’d try eliminating
the drugs in reverse order, to see whether he could
do without any drug therapy at all.

Dr. Gifford: Would you treat such a patient,
Dr. Schupp, and if so, how would you proceed?

Dr. Schupp: Every group has its own method of
treatment, and I think everyone uses the agents
with which he is most familiar. I don’t think one
would have to resort to apresoline or the gangli-
onic blocking agents. The case of moderate hyper-
tension that you have posed for us usually re-
sponds to moderate technics, and I would start out
with the diuretics. If they didn’t work, I’d then go
to the rauwolfia compounds. I think they usually
would work.

Dr. Gifford: My second choice after the thiazide
would be apresoline, and I’d go to reserpine after
that.

Dr. Schupp: For what reason?

Dr. Gifford: Chiefly because I believe the side
effects of reserpine are more to be feared than the
side effects of hydralazine. I refer mainly to depres-
sion. I have seen both reserpine depression and hy-
dralazine lupus, and the former is the more disa-
bling. If we keep the dosage of reserpine below 0.25
mg./day, we aren’t likely to have trouble with de-
pression. If we keep the dose of hydralazine below
300 mg./day, as Dr. From has said, we aren’t like-
ly to produce lupus. It is mainly because I think
patients who are taking hydralazine suffer fewer
side effects than do those using reserpine, my
second choice. However, I have no great quarrel
with anyone who chooses to reverse that order.

Unidentified questioner: How long a time would
you allow to pass before changing medications?

Dr. Gifford: Well, that would depend upon how
often the patient’s blood pressure is taken. If the
patient came in every day, I think a week would
be long enough to show whether the medication
were producing the desired effect. If the patient
came in only once a week, I’d wait until I had
taken three or four readings.

Questioner: Would you stick to Diuril?

Dr. Gifford: Yes, since there is no question that
all these drugs are more effective if the patient
is pretreated with a thiazide diuretic. I think that
is unequivocal.

Dr. Schupp: How low do you seek to make the
blood pressure fall?

Dr. Gifford: I like to get it to normal under ordi-
nary circumstances. In a patient such as I de-
scribed, I’d like to see the diastolic averaging 90
or less and the systolic averaging 140 mm. Hg or
less.

Questioner: Do you restrict sodium?

Dr. Gifford: I reduce the patient’s weight by
putting him on a reducing diet, but I don’t restrict
sodium unless there is complicating congestive
heart failure. What do you do about diet, Dr.
Schupp?

Dr. Schupp: Well, I have a patient in the hos-
pital now who had been on diuretics and developed
generalized edema, with a consequent rise in blood
pressure, after eating a bag of popcorn. Thus, I
don’t think there is any doubt that patients can
cancel quite a bit of the effect of diuretics by over-
loading themselves with salt.

Dr. Gifford: With normal kidney and heart func-
tion, I think the average person will be able to
tolerate a normal amount of sodium.

TREATMENT OF A MORE SEVERELY HYPERTENSIVE
PATIENT

Now let’s pose a different sort of problem. Let’s
take the same patient, 45 years old and without
any complications or symptoms, but let’s suppose
that his diastolic pressure averages 140 mm. Hg,
and that the fundus shows more narrowing and
some intense focal constrictions of the arterioles
and a few exudates. How do you start treatment.
Dr. From?

Dr. From: The patient’s diastolic pressure is now
at a more dangerous level. In such a case, one
worries about the possibility of cerebral hemor-
rhage, about whether heart failure may be im-
minent and about what may be going on in the
renal arterioles. In any event, however, we might
as well get the blood pressure down to normal
levels as fast as possible.

I would use intramuscular rauwolfia. I think it
has been adequately demonstrated that parenteral
reserpine will lower blood pressure adequately.
Admittedly, it has a lag effect, and if one fails to
keep that fact in mind, he may pile up a great
deal of the drug within the patient’s body and
suddenly get tremendous effects. There will also
be very important side effects such as depression
and a Parkinsonian stage. I'd start off with a 5
mg. dose, usually intramuscularly but occasionally
intravenously. If this didn’t bring the blood pres-
sure down within a two- or three-hour period —
and certainly if a second dose didn’t bring it down
— I’d then go directly to a ganglionic blocking
agent, intravenously. These ganglionic blocking
agents produce an orthostatic hypotension, and in

132

Journal of Iowa Medical Society

March, 1962

order to get the maximal benefit, we must elevate
the head of the patient’s bed a good 10 inches.

Hexamethonium (Bistrium) can be given intra-
venously without any difficulty at all. Occasionally
one can use parenteral apresoline, and there are
various other agents that can be used in various
hypertensive emergencies, but in the few cases
that I have encountered, reserpine intramuscular-
ly has brought the blood pressure down quite satis-
factorily.

Dr. Gifford: I assume, then, that you would hos-
pitalize any patient whose diastolic pressure was
140 mm. Hg or greater, even though he had no
symptoms or complications.

Dr. From: No, I said that if there were any pos-
sibility, from a clinical standpoint, that a hyper-
tensive crisis was occurring, I’d certainly want to
get the blood pressure down to normal as quickly
as possible. If the patient had walked into my of-
fice, and if there was no evidence that a catastro-
phe was imminent, I’d try treating him at home.
I surely wouldn’t use intramuscular reserpine
without hospitalizing him, however.

Dr. Schupp, what would be your regimen in a
situation like that?

Dr. Schupp: Even though the patient were ap-
parently well, I’d hospitalize him, for I think 140
mm. Hg is critical, and if something is about to
happen, the patient should be in the hospital. Sec-
ond, I’d prime him with a diuretic. Then I’d put
him on a ganglionic blocking agent. I wouldn’t use
an intravenous ganglionic blocking agent for this
type of patient, however. I’d use it only on a pa-
tient in a so-called hypertensive crisis.

Dr. Gifford: You’d go directly, then, from the
thiazide diuretic to a ganglionic blocking agent
without trying reserpine or hydralazine?

Dr. Schupp: With a diastolic pressure of 140
mm. Hg, I’d prime the patient for the first two or
three days with diuretics.

Dr. Gifford: I agree with you on that point. It
has been my experience that when the diastolic
pressure starts out at 140 mm. Hg or more, the
chances of its responding to thiazide, hydralazine
and reserpine are just about nil. I’d use the thia-
zide diuretic and treat the individual on an out-
patient basis, unless there were symptoms of im-
pending failure or hypertensive encephalopathy. I
believe I’d then go directly to a ganglion blocking
agent or to the new Ciba preparation Ismelin
(guanethidine), a sympathetic-inhibiting drug
which I have found to be very effective in these
severe cases.

Dr. From: I have used Ismelin orally, and I
think it an extremely effective drug. It has one
singular advantage in that the patient knows im-
mediately when it is getting him into trouble. An
overdose produces diarrhea. With the older drugs
such as hexamethonium and Ansolysen, constipa-
tion usually was a very great problem, and in fact
cathartics or enemas had to be prescribed with
them so that the patient could evacuate each pre-
vious day’s dose.

THE ANTI HYPERTENSIVE TO TAKE TO A DESERT ISLAND

Dr. Gifford: If you were to choose one and only
one antihypertensive agent to take with you to
the proverbial desert island, which one would you
take.

Dr. From: I’d take an oral diuretic.

Dr. Schupp: I think I’d take hydralazine.

Dr. Gifford: Now, suppose you were permitted
to choose two.

Dr. From: I’d take an oral diuretic plus a gang-
lionic blocking agent. As far as we know today,
hypertension can be blamed upon some anatomic
imbalance associated with vasoconstriction, and
a ganglionic blocker can at least break through
that cycle pretty well.

Dr. Schupp: In addition to my first choice, I’d
take chlorothiazide because of its potentiating
effect.

Dr. Flocks: Many years ago it was supposed that
a sympathectomy constituted the procedure of
choice. Can you say something on that subject?

Dr. Gifford: Well, we quit doing sympathecto-
mies at the Mayo Clinic in about 1953, with the
advent of the new drugs. Previously, we had done
an average of 250 to 300 of them each year, but
since then I doubt that we have done as many as
25 all together. Now, we feel that antihypertensive
therapy is superior, though I’d hate to have to de-
fend that position against Dr. Smithwick. It’s cer-
tain, at least, that one would have a hard time con-
vincing a patient that he needed major surgery
when friends of his with the same diagnosis were
all taking hypotensive drugs.

TREATMENT FOR THE SPECTACULARLY SEVERE
HYPERTENSIVE

Now, if the patient had a group IV fundus, a
diastolic pressure of 150 mm. Hg, and no symp-
toms or complications, what would be your pro-
gram of treatment?

Dr. From: I would always use the oral diuretic
as the basis of my total therapy. Certainly in this
case I’d use a ganglionic blocking agent. I feel, as
many others do, that if these drugs have undesira-
ble side effects, the dangers that they pose are pro-
portional to the sizes of dose administered. If we
use all of the drugs, we can get by with smaller
doses of each, getting the blood pressure down
and avoiding the undesirable side effects. I prefer
to use single tablets of each drug, incidentally,
rather than tablets containing combinations of
drugs, since I think the former technic gives one
a better control of the situation.

Dr. Schupp: I would use the ganglionic blocking
agents, and I’d use them intravenously.

Dr. Fatland: Drs. Hutchinson and Evans, of the
Lahey Clinic, have recently published an article
entitled “Should Sympathectomy Be Abandoned?”
and one of the questions that they have asked is
whether, in the case of a young patient, one should
ever consider offering or suggesting sympathec-

Vol. LII, No. 3

Journal of Iowa Medical Society

133

tomy in preference to a long and tedious drug
therapy. What would be your answer?

Dr. Gifford: I’d advise surgery only if the blood
pressure couldn’t be controlled adequately by tol-
erable doses of medication, or if the patient were
unwilling to cooperate in the drug program.

Dr. Schupp: When there is a severe renal in-
volvement, how low are you willing to take the
blood pressure?

Dr. Gifford: I’d take it down very gradually un-
til the blood urea nitrogen, or whatever one is
measuring, starts going up.

Dr. Schupp: And how about the cerebral symp-
toms?

Dr. Gifford: If cerebral vascular insufficiency re-
curs intermittently, I prefer that the patient
should remain for some time on long-term anti-
coagulant therapy. Then, when I finally begin tam-
pering with the blood pressure, I take it down
gradually, watching the patient’s symptoms with
great care.

Dr. Schupp: Some authorities maintain that one
should take the blood pressure down before giving
the patient long-term anticoagulant therapy.

Dr. Gifford: I don’t have that much courage.

Dr. Schupp: Then there are other authorities
who feel one shouldn’t take the blood pressure
down.

Dr. Gifford: My system has been fairly satis-
factory, and it is the one that I prefer. I’d dread
taking the blood pressure down if the patient
weren’t protected by means of anticoagulant ther-
apy. Now if a patient had a history of a stroke
five years ago, and had no residual, then I’d treat
his high blood pressure less cautiously and without
anticoagulant therapy unless symptoms of cerebral
vascular insufficiency ensued.

Dr. Schupp: In your formal paper, Dr. Gifford,
you mentioned some instances in which surgery
disproved a clinical diagnosis of pheochromocy-
toma. How frequent have they been?

Dr. Gifford: I’d guess that we’ve had 10 per cent
negative explorations.

Dr. Schupp: And do you feel that there might be
tissue other places in the body that you might have
missed?

Dr. Gifford: Well, we’ve thought so in some in-
stances, but we have never proved it.

An Organic Theory of
Mental Illness

Dr. W. J. Fessel, of the University of California
at San Francisco, has offered an organic theory of
mental illness in the February issue of archives
of general psychiatry. Although he says that the
evidence is “admittedly slim,” such a theory could
explain some of the many biochemical abnormal-
ities of the blood that have been discovered in the
mentally ill. He does not suggest, however, that
all types of mental illness may have this physio-
logic origin.

Reviewing developments in the past 10 years,
Dr. Fessel says that there is a large body of sci-
entific evidence that blood-protein abnormalities
occur in the mentally ill. These include an eleva-
tion of certain globulins, a class of proteins which
are largely antibodies, and some studies have
shown that protein substances can cause a be-
havioral disturbance in man.

Dr. Fessel says he himself recently confirmed
the presence of a significant elevation of the class
S19 microglobulins in persons with so-called func-
tional acute mental disturbances, in comparison
with a group of unselected blood donors. The
presence of these macroglobulins, which often

have antibody-like activity, may imply an auto-
immune factor in the chain of events leading to
the mental disturbance, he thinks.

As to why antibodies attack an individual's own
cerebral material, Dr. Fessel speculates that cer-
tain components of the nervous system, because
of their relatively late development before birth,
may not be recognized by the body’s immunity
mechanism as “self,” but are reacted to as “for-
eign.” Further support for the autoimmune theory
is found in studies that have revealed an abnor-
mal immunity response to various vaccines among
mental patients.

“The idea that autoimmunization is a factor in
the genesis of some functional psychoses might
be thought naive in view of all that is known
about the importance of other, e.g., psychosocial
and genetic, factors in their causation,” Dr. Fes-
sel concludes. “Yet such is the complexity of in-
terplay between cause and effect that these var-
ious mechanisms may be interdependent, the final
clinical expression being the delicately balanced
resultant of them all.”

The Significance of Pain in the

Diagnosis of Spinal Lesions

GEORGE FERRET, M.D.*

Iowa City

Pain is probably the most common and predom-
inant initial symptom of pathological processes
involving the spinal column and the meninges
of the spinal cord. The patient may have pain for
days, weeks, months or years, before developing
obvious signs localizing the pathological process
to one or another segment of the spinal column or
spinal cord.

Pain in the back of the head, the neck, the
shoulders and the upper extremities is an early
symptom of a lesion involving the cervical spine.
In lesions of the thoracic spine, it is commonly in
the interscapular region. It involves the chest,
the back, the costovertebral angles and various
parts of the abdomen. In lesions occurring in the
lumbar portion of the spine, the pain is most fre-
quent in the low hack, and radiates into one or
both lower extremities and into the scrotum, the
anus or the vulva.

The pain is usually aggravated by coughing,
sneezing, laughing, screaming, bending forward
or changing position. It usually occurs in attacks
that last from a few minutes to half an hour,
and these attacks may occur many times during
the day, depending upon the occupation and the
posture of the patient. Pain is often present at
night, or may be aggravated by resting on the
back. With severe back pain, the patient may walk
in a stooped position. He may hold his head and
neck stiff and extended. The pain may be so in-
tense as to waken the patient from his sleep or
keep him from lying down at night, or to keep
a child from playing or from eating. It may be so
intense as to require morphine for its relief.

The pain may appear, disappear and recur,
depending entirely upon the mechanical change
in position which either the patient or the lesion
may undergo. Pain arising from the spine may
simulate appendicitis, gallstones, renal calculi,
pleurisy, myocardial ischemia, gastrointestinal
tract ulcers, etc. The back pain may be interpreted
as unwillingness to go to school or to do chores,

* Division of Neurosurgery, State University of Iowa
College of Medicine, Iowa City, Iowa.

in children; as overwork or premenstrual tension,
in housewives; and as laziness, psychoneurosis or
malingering in otherwise healthy-appearing males.

I should like to present a series of short case
histories where pain was the initial and the pre-
dominant symptom. In many cases where no neu-
rologic deficit was present, or where other disturb-
ances on physical examination were absent, in-
tensive search for the cause of pain finally revealed
the nature of the disease and led to its treatment.
Pain caused by trauma, osteoarthritic changes and
degenerated or protruding intervertebral discs
will not be discussed in this presentation.

INTRADURAL TUMORS AND CYSTS

Case 1. An 8-year-old boy had experienced low
back pain off and on for a period of three years.
Because of this pain he had held his back stiff, and
while playing had always tried to protect the lower
portion of his back. In recent months, his back
pain had become worse. It was most severe when
he was trying to get up from the floor. He then had
to take hold of surrounding objects in order to
get up. He described his discomfort as a rather
vague, aching pain involving especially the midline
of the lower back. He walked stooped forward.

Examination revealed no neurologic deficit, but
the paravertebral muscles were tight. A partial
subarachnoid block was found at myelography,
and a dermoid tumor was removed from the region
of the 4th lumbar subarachnoid space (Figure 1).
The tumor, measuring 3 x 1.5 x 1.5 cm., had com-
pressed the cauda equina. The boy was free of
pain following the removal of the tumor.

Case 2. A 10-year-old boy had an eight-month
history of left hip pain. His pain was worse in the
morning, and better after he had moved around.
His pain was intermittent. He suffered for two
or three days and then was free of pain for two
or three days. One month before we saw him he
had hit a wire in his back yard in the dark, and
had fallen. His back had become stiff. The pain
in his left hip had increased. He refused to bend
forward to protect the left hip, and for the past
month had remained in bed. He refused to go to
school or to play. The pain was aggravated when
he stood, walked or sat. It was aggravated by
laughing.

On examination, he had positive Lasegue and
Kernig signs bilaterally, but no obvious neurologic
deficits. Spinal fluid studies were normal, but mye-

134

Vol. LII, No. 3

Journal of Iowa Medical Society

135

lography revealed a block at the 3rd lumbar verte-
bral level, and at operation a dermoid cyst was
removed. The cyst measured 4x2x2 cm. and
had compressed the cauda equina. The patient has
been entirely free of pain since operation.

Case 3. A 13-year-old boy gave a six-year
history of occasional pains in his lower back. He
could not bend his back because of pain. The
pain was aggravated when he sat or rode in an
automobile, or whenever some bending was in-
volved. During the past four years he had also
had radiating pain in his arms and especially in
his legs. He was treated with cortisone without
improvement. He then developed frequent charley-
horses in the thighs and calves, especially at
night. Finally, three and a half years ago, his
pain lessened, but then he developed weakness in
both legs. However, his cramps continued. One
year ago he became incontinent and became un-
dernourished. At operation we removed a dermoid
tumor that was compressing the cauda equina and
the conus medullaris from the 1st to the 3rd
lumbar vertebra. Unfortunately, at the time of

operation he had become incontinent, and he has
remained incontinent since.

Case 4. A 15-year-old girl for 11 years had ached
in her legs and buttocks. She had no memory of
freedom from pain. The most severe pain was in
her left lower extremity and at times it was so
unbearable that she couldn’t sleep, and she re-
mained up all night. Seven months ago she devel-
oped low back pain. One month ago she had in-
creased pain in her left hip. She had pain on the
external aspects of her left hip, knee, calf, dorsum
of her left foot, and also along the course of her
sciatic nerve. Her pain was worse when she put
her weight on her left lower extremity. The pain
would last for seconds only, but it recurred at
frequent intervals. She was unable to stand
straight because of her back pain, and she stooped
forward as she walked. The parents had noted a
scoliosis five or six years ago, and at the time I
first saw the patient she had weakness and sen-
sory disturbances in both lower extremities. At op-
eration multiple neurofibromas were removed from
her lumbosacral canal (Figure 2). The tumors

Figure I. Left: Dermoid tumor alter its removal from the cauda equina. The black thread is attached to the dermal sinus found
in the subcutaneous tissue. This sinus leads to the extradural portion of the tumor, which is connected through another sinus to
the intradural portion of the tumor. Both intra- and extra-dural portions of the dermoid are connected to the filum terminale by
a large blood vessel.

Right: Myelographic defect of the intradural portion of the tumor at the 4th lumbar vertebral level.

136

Journal of Iowa Medical Society

March, 1962

weighed 123 Gm. Since the removal of these
tumors, the patient has been completely free of
pain.

Case 5. This patient is a 16-year-old boy in
whom, four years ago, we diagnosed and explored
a medulloblastoma of the cerebellum, following
which he received x-ray therapy and was symp-
tom-free. Two months ago, while working at a
service station, he developed pain in the posterior
aspect of both lower extremities. This pain was
increased by bending. He also had a tight feeling
in the lower back. The pain was aggravated by
coughing and sneezing. The neurologic examina-
tion was essentially negative. Myelography of his
spine was performed because of his pain, and we
found a complete block at the level of the 4th lum-
bar intervertebral disc space (Figure 3). The
spinal fluid contained medulloblastoma cells. We
thought then that he had a metastasis from his
original cerebellar tumor in the tip of his cauda
equina, and he was given x-ray therapy. The boy
was already free of symptoms after the second
x-ray treatment.

Case 6. A 17-year-old girl gave a six-month
history of mid- and lower-thoracic pain which was
non-radiating in character. Neurologic examina-

Figure 2. Left: Lateral view of the lumbar spine demon-
strates the scalloping of the anterior aspect of the spinal
canal produced by the erosion of the posterior aspect of the
vertebral bodies by the tumors.

Right: Multiple neurofibromas removed from the roots of
the cauda equina.

tion and spinal fluid studies were normal. She was
seen at monthly intervals, always complaining of
midback pain, especially at the end of the day
when she was tired. Finally, eight months after we
first saw her, or 14 months after the onset of her
pain, she was admitted to the hospital. She stated
that two weeks prior to that time, for three days,
she had had sharp, stabbing pains in the inter-
scapular region, which was also tender to touch.
Coughing and sneezing did not increase the pain.
Breathing did not cause pain, but movement of
the shoulders did. Physical examination again was
entirely negative. However, roentgenograms of
the thoracic spine revealed an increase in the in-
terpedicular distances of the 6th, 7th, 8th and 9th
dorsal vertebrae. On that basis mylography was
carried out. An ovoid structure filled with dye was
demonstrated when the patient was in supine posi-
tion; it persisted in the upright position (Figure 4).
At operation, an arachnoid cyst at the level of the
bodies of the 7th and 8th dorsal vertebrae was
encountered and removed, and the patient has
been free of pain since then.

Case 7. A 5-year-old girl had a history of in-
termittent low back pain for six weeks. She also
had had pain over the anterolateral aspect of
the left thigh for the same period of time. The
parents reported that during a period of pain last-
ing several days, the child had not cared to play
or walk, but had remained in bed most of the
time. At other times, however, she had been free
of pain, and had had no difficulty in walking or

Figure 3. Myelographic block at the upper level of the
5th lumbar vertebra produced by a medulloblastoma metas-
tasis filling the bottom of the lumbosacral arachnoid sac. On
the right side, dye has escaped along lumbar and sacral
nerve root sleeves.

Vol. LII, No. 3

Journal of Iowa Medical Society

137

playing. Except for an area of hypertrichosis in
the lower lumbar region, examination was es-
sentially normal. On palpation, she had pain over
the lower lumbar and upper sacral spine. When
bending forward, she would not move her lumbar
spine and would keep it in the lordotic position,
and the paravertebral muscles were tense. Roent-
genograms revealed a widening of the entire lum-
bar canal, and were suggestive of a diastemato-
myelia. The child was seen again three months
later and she had had no more pain and no further
neurologic deficits. However, one year later the
girl complained again of low back pain occurring
during the day, and occasionally the pain would
wake her up during the night. She also had oc-
casional pain in the left leg. The parents noted that
the child did not stoop, but would squat down to
pick up objects from the floor. On examination,
straight leg raising also produced pain. Myelog-
raphy revealed a complete block at the level of
the 3rd lumbar vertebra and another small mid-
line defect at the level of the 4th lumbar vertebra.
At operation, a large arachnoid cyst was encoun-
tered compressing the lumbar cord, together with
diastematomyelia which split the cord below the
cyst. The bone spicule and the cyst were removed,
and the child has been free of pain since that
time.

EPIDURAL ABSCESSES

Case 8. A 13-year-old boy had fallen from a
tree ten days earlier, and two days after the fall

Figure 4. Arachnoid cyst o( the septum posticum filled with
pantopaque overlying the bodies of the 7th and 8th dorsal
vertebrae. This roentgenogram was taken after myelography
with the patient in standing position.

had had pain in the coccygeal region, swelling of
the right ankle and severe low back pain. On ex-
amination, we could only find spasms of the back
muscles. When spinal puncture was attempted,
pus was encountered before the needle penetrated
into the lumbar subarachnoid space. At opera-
tion, we found an abscess, paraspinal and ex-
tradural, mostly on the right side, in the lower
lumbar and sacral region. Drainage of this abscess
freed the patient of his pain.

Case 9. A 15-year-old boy had fallen ten feet
from a tree six weeks before we saw him. The
only immediately obvious injury had been a
sprained ankle, but two weeks later he experi-
enced back discomfort in the mid-dorsal region.
The pain seemed to be worse at night and obliged
him at times to walk the floor. The pain gradually
increased, and he found relief only by standing
with his back against the wall. Pain at the onset
was gradual. It was increased by riding in a car,
it was associated with pain along the lower ribs
on both sides, and it was aggravated by lying
down. During the final week before we saw him,
his pain had increased in severity, and then he
had developed numbness and weakness in both
legs.

When myelography was performed, we found
a spinal fluid block at the 7th thoracic level, and
at operation an epidural abscess was found, ex-
tending from the 7th to the 12th thoracic vertebra.
His pain was relieved by the evacuation of the
abscess, and his paraparesis disappeared.

Case 10. A 38-year-old truck driver stated that
14 days earlier he had had an attack of right upper
quadrantic abdominal pain that radiated to the
interscapular region. His pain had lasted for half
an hour. During the ensuing days he had had
several more attacks of pain. Five days later his
local physician examined him for gallbladder dis-
ease, but both gallbladder and gastrointestinal
tract studies were negative. The pain persisted,
and it was constant and localized mostly in the
interscapular region. It was so intense that the
patient had to remain in a sitting position, and
was able to lie neither on his back nor on either
side in bed. Sneezing, swallowing and coughing
aggravated his pain. He also had marked tender-
ness over his spine between the scapulae, and once
fell because of pain when his physician had
touched him in that area. Two days before we
saw him he had developed numbness and weak-
ness in his legs, and loss of control of bladder and
bowels. He had no fever.

Examination revealed sensory loss below the
1st lumbar dermatome. There was complete block
on spinal fluid studies. Because of his exquisite
tenderness in the mid-dorsal region, a laminectomy
was performed and an abscess was evacuated from
the epidural space between the 4th and the 7th
dorsal vertebra. He was relieved of his pain, and
he gradually improved from his paraparesis.

Case 11. A 45-year-old woman had a long history
of diabetes mellitus. She gave a two-week history

138

Journal of Iowa Medical Society

March, 1962

of feeling what she interpreted as “gas pain in
the stomach.” This had been followed by pain
between the shoulder blades. The pain had been
so intolerable that she couldn’t continue working.
She had then developed abdominal pain radiating
to both costovertebral angles, and occasionally to
the groin. The local physician had hospitalized her
with a diagnosis of kidney infection. He found
sugar in the urine. The pain subsided while she
was in the hospital, but recurred in the costo-
vertebral area as soon as she had been discharged.
She developed more right lower quadrant pain
and marked tenderness in both costovertebral
angles. The back pain was aggravated by motion
and was relieved when she was flat in bed.

When she was examined here, she had tender-
ness over the lumbodorsal spine and restricted mo-
tion of the spine. Most tenderness was present over
the 8th, 9th and 10th dorsal vertebrae. She also
had a constant fever and a positive Kernig’s sign.
On the twenty-fourth day of hospitalization, ex-
amination revealed a hypalgesic band around the
trunk in the 7th to the 9th dorsal dermatomes.
Spinal-fluid findings were normal. On the twenty-
ninth day, a dorsal subarachnoid block was found
at myelography. In the meantime, the patient had
had a number of x-ray examinations. Films of the
cervical, dorsal and lumbar spine revealed degen-
erative joint disease. Roentgenograms of the chest
were normal. Intravenous pyelograms were nor-
mal. Cholecystograms were normal. The stomach
and the duodenum were reported normal. The
colon was normal. Finally, we had a positive mye-
logram, and at operation an epidural abscess was
found between the 5th and the 8th thoracic verte-
bra. This abscess seemed to arise from the 7th
dorsal intervertebral space. Later the body of the
7th dorsal vertebra collapsed and a gibbus de-
veloped. The diagnosis was epidural abscess sec-
ondary to osteomyelitis.

VERTEBRAL TUMORS

Case 12. A 10-year-old boy had had severe pain
in the middle of his neck for eight months. This
pain radiated into his right little finger. He carried
his head flexed to the right to protect his neck
against pain. The pain woke him up at least once
a night and was relieved by aspirin. He even took
aspirin to school with him. His local physician
thought he was dealing with a torticollis, and cut
the boy’s right sternomastoid muscle proximally
and distally, but this did not end his pain. He
gradually stiffened his neck more and more in
order to guard against motion, particularly ex-
tension and rotation. The pain could be repro-
duced by pressure over the mid-cervical area, by
rotation of the neck to the right, and by extension
and flexion of the head to the right.

The neurological examination was essentially
normal. Cervical roentgenograms revealed a small
mass in the lateral aspect of the right side of the
4th cervical vertebra. At operation, an osteoid
osteoma was removed from the vertebra, and the
patient has been asymptomatic since.

Case 13. A 14-year-old girl had had upper back
pain for two and a half months. Her pain was not
very severe, but was gnawing and lasted for two
weeks. One month ago she developed a recurrence
of back pain, with tightness of her back, and one
week ago weakness and spasticity in her lower
extremities. Roentgenograms suggested a destruc-
tive process involving the posterior arch of the
3rd dorsal vertebra, and the myelograms revealed
a subarachnoid block at the inferior border of the
4th dorsal vertebra. At operation, we found a tu-
mor involving the bone, the dura and the sur-
rounding muscles between the 2nd and the 4th
dorsal vertebra. This tumor was diagnosed by
some as a giant cell tumor, and by others as an
osteogenic fibroma. Four months after discharge
from the hospital the patient was free of pain but
still had a spastic paraparesis.

Case 14. An 11-year-old girl, for six weeks, had
had pain in the upper dorsal region and between
the scapulae. This pain was present usually only
on anterior flexion of the neck. Three weeks be-
fore we saw her she had developed weakness in
both lower extremities. X-ray films of the dorsal
spine showed an abnormal formation of bone on
the right side of the upper dorsal vertebrae (Fig-
ure 5). At operation we found an osteoblastic le-
sion involving the 4th and 5th dorsal vertebrae,
which was diagnosed as an osteochondroma. When
last seen, the girl was asymptomatic and leading
a normal life.

Case 15. A 59-year-olcl county superintendent of

Figure 5. Roentgenogram of the thoracic spine showing
changes produced by osteochondroma arising on the right
side of the 4th and 5th dorsal vertebrae.

Vol. LII, No. 3

Journal of Iowa Medical Society

139

schools had had intermittent pain in the lower por-
tion of her back for the past fifteen years. Her pain
sometimes radiated into the lower extremities, and
was also relieved by frequent osteopathic treat-
ments. Two months before we saw her she finally
developed sensory disturbances in both lower ex-
tremities. A central myelographic defect was pres-
ent between the 12th dorsal and the 1st lumbar
vertebra (Figure 6), and at operation an enchon-
droma was encountered on the anterior aspect of
the spinal canal arising from the intervertebral
disc and the surrounding bone. The patient was
free of pain when discharged from the hospital.

Case 16. The last case is that of a 70-year-old
woman who had been operated upon four years
earlier for a rectal carcinoma. One year ago she
developed pain in the sacral region and in both
lower extremities. She was unable to walk because
of pain, and she was unable to sleep. Roentgeno-
grams revealed destruction of the sacrum and the
5th lumbar vertebra. This was thought to have
been caused by carcinomatous metastases, and the
patient’s previously intractable pain was relieved
completely by a bilateral anterolateral cordotomy.

CONCLUSION

I could go on enumerating many more cases of
tumors, abscesses and metastases, involving the
cauda equina, the spinal dura mater, the epidural
space, and the vertebral bony structures. Back pain
must be taken seriously. Several of the patients in
the cited cases could have been cured before they
developed paralysis, sensory disturbances and loss

Figure 6. Midline defect seen in the myelogram at the
level of the 12th dorsal vertebra. This defect was produced
by an enchondroma arising on the anterior aspect of the
spinal canal.

of sphincter control, if more attention had been
paid to their pain.

Back pain in children is uncommon but, when
present, is highly suggestive of an underlying path-
ologic process, usually a benign tumor. Epidural
abscess starts with acute severe back pain which
develops suddenly, which may or may not be con-
nected with a previous infection, and which rapid-
ly results in severe signs of spinal cord compres-
sion or softening. These are more common in
adults, young or middle-aged. In contrast, the back
pains that develop in older people are commonly
the result of metastatic involvement of the verte-
brae or of the para- or intra-spinal tissues.

The pain created by destructive lesions from
metastatic tumors is best treated by unilateral or
bilateral cordotomy, whereas the pain of primary
spinal tumor or infection is best treated by early
removal of the lesion.

Intramedullary tumors rarely give rise to pain.
However, such cases have been reported in the
literature. Even syringomyelia has been known
occasionally to produce pain.

It is important that the diagnosis of a spinal
lesion be made before the development of para-
paresis, paraplegia, quadriplegia, or loss of bladder
and bowel control. The following are points that
can be helpful in arriving at the diagnosis:

1. An investigation of the history of pain and
its previous treatment.

2. An examination of the posture of the patient
to determine whether kyphosis, lordosis or scoliosis
is present.

3. Discovery of muscle spasms in the paraverte-
bral region, and points of tenderness on palpation
of the spine.

4. Detection of disturbances in gait.

5. Disturbances in motion of the spine, or pain
on moving the spine forward, backward, or to
either side, or on rotation.

6. Increase in pain on stretching the nerve roots
or spinal cord, by motion of the spine or the ex-
tremities. I refer to the Kernig and Lasegue tests,
and anterior flexion of the neck.

7. A careful study of the area of referred pain,
remembering that it might be dermatomal, point-
ing to a certain localization within the spinal canal.

8. Careful neurologic examination, with special
attention being drawn to areas of possible numb-
ness, tingling or burning.

9. Careful interpretations of roentgenograms of
the spine taken in various positions or in various
planes. Spine films should be taken in antero-
posterior or postero-anterior positions, in lateral
positions, in oblique positions, in flexion and in
extension of the spine.

10. Carefully performed spinal fluid studies, with
manometric pressure readings, determination of a
partial or complete block by Queckenstedt’s ma-
neuver, and studies of the spinal fluid cells and
protein, and occasionally sugar and culture.

11. Finally, when one suspects an intraspinal
lesion, myelographic studies.

Bone Physiology

DAVID G. MURRAY, M.D.

Iowa City

In recent years, basic investigations into the nature
and function of bone have been accelerated, and as
a result of an increase of interest and of the de-
velopment of improved research tools, a clearer
concept of the physiology of bone has begun to
emerge.

Considered as a tissue, bone is a complex com-
bination of inorganic and organic materials organ-
ized to support the body, to provide for growth and
to serve as a mineral reservoir.

CHEMISTRY OF BONE

The inorganic fraction of bone is a crystalline
substance that belongs to the “hydroxyapatite”
group of compounds — ones having similar ionic
arrangements for which the prototype is Ca10-
(P04)i; (OH) 2. The average crystal is a rod-shaped
structure roughly 50 Angstrom units in diameter,
and of indeterminate length. The internal struc-
ture of the crystal is an arrangement of ions in a
three-dimensional lattice. Reducing the ratio of
the constituent ions to the smallest whole number
defines the “unit cell,” and it is the organization
of these cells that forms the crystal.

Actually, not all unit cells are identical in com-
position, for substitution of ions may occur with-
in the cell, and impurities may be included be-
tween the units as the bone crystal forms. Con-
sequently, bone salt is not a homogeneous ma-
terial, and attempts to characterize its exact
chemical composition have led to much confusion
in the past. The major ions are calcium and phos-
phorus, in a ratio of 1.5 to 1. Additional ions of
sodium, potassium, manganese, carbonate, citrate,
chloride and fluoride are consistently present, but
in varying amounts.

Because of the small size of the crystals, from
one half to two thirds of the unit cells are on the
surface of the crystal, giving an extremely large
surface area in proportion to mass. The skeleton
of a 150-pound man has about 100 acres of crystal
surface.

Each crystal is surrounded by fluid, which pro-
vides for extensive ionic interchange. The crystal
surface is continuous with a tightly bound layer

Dr. Murray is a resident in the Department of Orthopedic
Surgery at the S.U.I. College of Medicine.

of hydrated ions, and external to that is a more
loosely held layer of water. This “hydration shell”
is so tightly bound to the crystal that it cannot be
removed by drying at 100° C. The volume of the
hydration shell may be greater than that of the
crystal itself, and provides the medium through
which ions penetrate from the body fluids and are
incorporated into the crystal.

The organic component of bone makes up 35 per
cent of the dry fat free weight, and is composed of
collagen and ground substance. The collagen of
bone accounts for 90 to 95 per cent of the organic
fraction, and is similar to collagen from other
sources. Specifically, it is an organization of
macromolecules, each consisting of three poly-
peptide chains, and the result is a fibrillar material
with a high degree of structural regularity. The
fibrils are of indeterminate length, with double
cross banding at 640 A intervals. Collagen is solu-
ble in dilute acid, and can be reconstituted into its
original form. It is now thought that the collagen
plays an important part in initiating crystal for-
mation. During this process, crystals form on and
within the collagen, with their long axes parallel
to the axis of the collagen fibril and initially in
relation to the dense cross bands.

The ground substance of bone matrix is the ex-
tracellular and interfibrillar component of bone.
This is a poorly defined substance consisting large-
ly of mucopolysaccharides, held together by pro-
tein bonds. Of the several mucopolysaccharides,
chondroitin sulfate A, keratosulfate and hyalura-
nate are found in bone.

THE PHYSIOLOGY OF SUPPORT

Wolff, in 1885, was among the first to emphasize
the active or adaptive role of bone as a supporting
structure. “Wolff’s law,” as it has come to be
called, is as follows: “Every change in the form
or the function of a bone, or of its function alone,
is followed by certain definite changes in its in-
ternal architecture and equally definite secondary
alterations in its external conformation in ac-
cordance with mathematical laws.” This postulate
has served as a foundation for modern studies of
the structure and adaptability of bone.

Fi'om an anatomic standpoint, the structural
unit of compact bone is the osteon or Haversian
system, consisting of a central canal containing
vessels and nerve, surrounded by concentric layers
of bone with prominent cement lines and radially
arranged osteocytes. Individual osteons branch and
anastomose with one another following the cen-

140

Vol. LII, No. 3

Journal of Iowa Medical Society

141

tral vessels and forming a continuum rather than
an elaborate conglomeration of individual building
blocks. On the surfaces of compact bone, circum-
ferential lamellae are laid down by the periosteum
and endosteum.

Remodeling of the osteons occurs continuously
throughout the life of the human being. Absorp-
tion cavities containing blood vessels and connec-
tive tissue occur within the bone, encroaching upon
mature osteons. At a certain point, resorption
ceases, and rebuilding begins with the formation of
a new osteon. The time required for the complete
cycle is about 10 to 12 weeks, at which point the
new osteon is 90 per cent mineralized. Mineraliza-
tion then continues at a slow rate for the next
five months or longer. During the period of rapid
mineralization, the osteon is described as active or
metabolic. As activity subsides, the unit is termed
inactive or structural bone, and as such it plays
little part in ionic interchange until it is en-
croached upon by another absorption cavity.

The continuous remodeling explains the method
by which a bone, when once formed, adapts to
various intrinsic and extrinsic influences. There is
an inherent factor in the embryological formation
of a bone that determines its general shape, but
physical factors play an important part in forming,
preserving and altering the ultimate structure. It
has been shown that a long bone isolated from a
chick or mouse fetus and grown in tissue culture
will acquire a fairly normal shape at one point in
its development. With further growth, however,
distortion takes place, particularly in areas nor-
mally supported or influenced by muscle attach-
ments or weight bearing. A clinical example of this
can be seen in congenitally dislocated hips, where
the muscle and joint relationships are altered and,
as a result, the typical contour and trabecular pat-
tern of the femoral head and neck and of the
acetabulum fail to develop.

In addition to the changes that occur in em-
bryonic or developing bone, the adaptability of
mature bone to extrinsic stress factors has been
demonstrated by numerous experiments. When
the normal stress on a bone is diminished, as in
paralysis or immobilization of an extremity, mod-
erate to marked atrophy or osteoporosis of the
bone will result. From 25 to 50 per cent of the min-
eral may be lost by the time rarefaction becomes
apparent on x-ray. Rapid demineralization of large
areas of the skeleton may be associated with hyper-
calcemia and increased calcium in the urine. With
restoration of normal stress patterns, bone density
returns to normal.

When the normal architecture is completely dis-
rupted by fracture and subsequent malunion, the
bone makes a definite attempt to remodel itself in
accordance with the altered lines of force. This
capacity for remodeling is particularly evident in
young bones, where marked deformities are com-
pletely realigned over a period of several years.

THE PHYSIOLOGY OF GROWTH

Serious investigations of the mechanism of bone
growth date back to the Eighteenth Century. John
Hunter’s classic experiment using lead pellets im-
planted in the leg bone of a pig demonstrated that
bones grow in length only at the ends. Almost
simultaneously, it was discovered that madder,
which produces a red dye, would stain newly
formed bone when it was fed to growing animals.
Using this material, various investigators were
able to show that a bone grew in circumference
by apposition of new bone on the surface, and that
the most active new-bone formation occurs at the
ends of the bone.

Since that time, a number of other substances
have been found that will be incorporated into
new bone. Recently, attention has been focused on
tetracycline, which is bound to the collagen of
newly-forming bone. This substance fluoresces
brightly when viewed under ultraviolet light, de-
lineating the active osteons. Similarly, radioactive
isotopes of calcium and phosphorus will be in-
corporated into bone salt and can be demonstrated
by microradiographs or external radiation count-
ers. Such technics as these are being used ex-
tensively today in studies of the growth processes
of bone.

In the embryo, bones develop in two character-
istic manners. In most instances, bone forms in
a preexisting cartilage model through the process
of endochondral ossification. The remaining group,
notably the flat bones of the skull, ossify directly
from mesenchymal tissue by means of intramem-
branous ossification. As bone growth continues
after birth, the increase in length occurs at the
epiphyses, as endochondral ossification, whereas
appositional growth on the surface is intramem-
branous in nature. Growth at the epiphyses con-
tinues through puberty, at which time the epiphys-
eal plates close.

The blood supply of the epiphyseal plate is de-
rived from the epiphyseal side, and consists of
many capillaries which enter the cartilage of the
resting zone and penetrate to the proliferative
zone but do not cross the entire plate. Destruction
of this blood supply will distort the pattern of the
entire epiphyseal plate and bring about early
closure. The blood supply on the metaphyseal side
consists of capillary buds growing into the area of
disintegrating cartilage cells. Interruption of those
vessels will result in widening the epiphyseal plate
temporarily as a result of continued cartilage pro-
liferation without ossification. With reestablish-
ment of the metaphyseal vessels, the plate is re-
stored to its normal width.

Of the naturally occurring factors that influence
the rate of a bone’s growth, the one most commonly
encountered is trauma. Although it is obvious that
a fracture across an epiphyseal plate, with disrup-
tion of cells, can cause a growth arrest, it is more
difficult to explain why a fracture some distance
from the plate can accelerate growth. It can be

142

Journal of Iowa Medical Society

March, 1962

shown, however, that the overgrowth is a result
of stimulation of the main growing epiphyseal
plate of the involved bone, probably through an
increased local blood supply.

Radiation on the epiphysis is to be considered
in the same general category as trauma. Small
doses directly to an epiphyseal plate produce tem-
porary disorganization of the cells. Larger doses,
in the neighborhood of 1800 to 2600 r., cause gross
cellular disorganization and permanent growth
arrest.

Attempts have been made to estimate the force
exerted by the growing bone. A group of investi-
gators using calves showed that a pressure of 560
pounds must be exerted before a measurable re-
tardation is produced. Transposed to human be-
ings, this represents a far greater sustained pres-
sure than ever occurs physiologically. Although
such pressures can be obtained surgically, through
the insertion of steel staples across an epiphysis,
even such staples have been straightened and
broken by the force of the growing plate.

Hormonal influences play a large part in general
bone growth, although only the growth hormone
secreted by the anterior pituitary appears to exert
a specific effect upon the epiphyseal apparatus.
Hypophysectomy in experimental animals leads to
prompt growth arrest, and growth resumes fol-
lowing the administration of growth hormone. At-
tempts to stimulate growth in dwarfs through the
administration of this hormone derived from
bovine sources have been disappointing. However,
recent experiments using human growth hormone
have been effective in stimulating growth where
epiphyseal plates had not yet closed. A species
specificity for this hormone has thus been indi-
cated.

A deficiency in thyroid hormone results in
dwarfism, if present at birth. Many studies on the
effect of thyroid hormone alone on growth have
seemed to indicate that it has a nonspecific effect
on growth that may reflect the effect of thyroid
hormone on the general metabolism. An overdose
of thyroid hormone will promote a temporary in-
crease in growth, but will result in early closure of
the epiphyses.

Chorionic gonadotropin and androgens have been
shown to have a stimulating effect on growth, but
to cause a premature development of sexual
characteristics. The effects are similar to those of
the growth hormone of the anterior pituitary.

Certain compounds have been used experi-
mentally to distort growth. The most notable of
these is an extract of the sweet pea ( Lathy rus
odoratus) seed, which when administered to the
young animal will cause distortion of the epiphys-
eal plate and loosening of ligamentous insertions,
with resultant structural deformities including
scoliosis and slipped epiphyses. A decrease in the
synthesis of mucopolysaccharides and an increase
in the fragility of the collagen fibril have been ob-
served. Recently, a proteolytic enzyme “papain,”

when administered parenterally, has been shown
to produce changes in the epiphyseal plate, even to
the extent of premature closure. The enzyme de-
stroys the protein bonds in the cartilaginous ma-
trix, liberating large quantities of mucopolysac-
charide into the blood stream.

Various genetic factors play a role in bone
growth. Aside from the factors that determine
general body size and shape, certain genes have
been associated with specific abnormalities. For
example, achondroplasia, inherited as a single
dominant factor, causes a characteristic shortening
of all the long bones. A number of other abnor-
malities of growth are thought to be of genetic
origin, but for the most part, too few cases have
been studied or insufficient information has been
gathered to permit the drawing of positive con-
clusions.

PHYSIOLOGY OF THE MINERAL RESERVOIR

The normal adult skeleton contains 1200 Gm. of
calcium and 600 Gm. of phosphorus, accounting for
99 and 90 per cent, respectively, of the total body
content of each. There is a constant and rapid ex-
change of these ions between plasma and extra-
cellular fluid, and between extracellular fluid and
bone, to the extent that an individual ion rarely
stays in the plasma for more than a minute. Hast-
ings and Huggins, using dogs, found that they could
replace 50 per cent of the blood volume with hy-
pocalcemic blood every 10 minutes without lower-
ing the blood-calcium level significantly. This rep-
resents a tremendous capacity of bone for home-
ostatic regulation.

The most rapid exchange occurs at the crystal
surfaces, particularly in the active osteons. A
secondary and much slower exchange takes place
within the crystals. The inactive osteons constitute
a relatively inaccessible compartment or “non-ex-
changeable bone.” It would seem reasonable that
this rapid interchange of calcium and phosphorus
ions between the solid and the solution phase must
be a simple function of the solubility of the bone
salt, but such apparently is not the case, for many
attempts to explain the phenomenon purely on a
solubility basis have failed to produce a satis-
factory answer. Several factors complicate the
problem. First, bone salt is not a simple solid of
constant ionic composition. Second, equilibrium
between solid and liquid phases is reached very
slowly in vitro. Third, the relation between the
bone salt and the surrounding fluid is altered by
such extraneous biologic factors as age, para-
thyroid activity and nutritional adequacy.

In addition to the principal elements in the
skeleton — calcium and phosphorus — a number of
other elements are stored in bone. Of these, sodium
and manganese are mobilized when needed. Other
elements, when once deposited, may remain for
life, and thus serve no known physiologic function.

The kidney plays an essential role in regulating

Vol. LII, No. 3

Journal of Iowa Medical Society

143

the circulating mineral concentration. This organ
actually conserves calcium more efficiently than
water, filtering and then reabsorbing actively, in
the distal tubules, all but the calcium in com-
plex forms, achieving 99 per cent reabsorption. It
does the same for phosphate. In chronic renal in-
sufficiency, an increased load is placed on the bone
reservoir, and rickets or osteomalacia may occur.

Another factor in mineral regulation is the in-
testinal tract, through which the elements gain en-
trance to the body. Evidence suggests that calcium
absorption is under hormonal control, and is not
related solely to gross intake. Phosphate absorp-
tion, on the other hand, seems to occur largely by
passive diffusion. Abnormally high concentrations
of either ion in the intestine will inhibit the ab-
sorption of the other. Other factors such as faulty
digestion of fats will prevent absorption and may
result in osteomalacia.

The concentration of calcium and phosphorus in
the serum is regulated within narrow limits by the
secretion of the parathyroid glands. Parathyroid
hormone affects the cellular elements of bone and
kidney, increasing calcium mobilization from bone,
and decreasing the calcium reabsorption by the
renal tubules. The mode of action is termed the
“feed back mechanism,” and is the means by which
a fall in serum calcium below its normal level of
10 mg./lOO cc. stimulates the secretion of para-
thyroid hormone. This, in turn, causes an increase
in the mobilization of calcium from bone and raises
the serum concentration. In the absence of para-
thyroids, the serum calcium stabilizes at about
7 mg./lOO cc., indicating that at this level the
serum may be in equilibrium with the bone phase.
With excess parathyroid hormone, the serum cal-
cium may reach levels as high as 15 mg./lOO cc.,
with greatly increased resorption of bone and with
fibrous tissue replacement. Bone repair takes
place rapidly, once the source of excess hormone
has been removed.

From a nutritional standpoint, vitamin me-
tabolism has been closely linked with bone, al-
though the relationship is not clear cut in all
cases. Vitamin A plays a role in general bone and
cartilage metabolism, and a deficiency in animals
leads to a suppression of growth and remodeling
of the long bones. A gross excess in infants causes
painful swelling, with periosteal thickening of the
long bones. Isolated tissue culture experiments in-
dicate a specific effect on the intercellular matrix
of cartilage.

The B-complex vitamins affect tissues, which
respond more rapidly than bone, and hence bone
changes are not generally associated with defi-
ciencies of this group.

Vitamin C is concerned with the formation of in-
tercellular supporting substances such as collagen
of bone, cartilage and fibrous connective tissue. A
deficiency results in the clinical condition known
as scurvy, in which collagen fibers are absent or

deficient, and in which ossification fails to take
place. In addition to the other stigmata of scurvy,
epiphyseal separation in children and failure of
fracture-healing can be seen. Although the actual
process of calcification is not affected, the absence
or defective formation of matrixes prevents os-
sification.

The prime effect of vitamin D is to promote the
absorption of calcium from the intestine. It also
complements the action of parathyroid hormone in
promoting the mobilization of calcium from bone.
Lack of vitamin D results in calcium deficiency in
the serum, with consequent defective calcification
of cartilage and the osteoid characteristic of
rickets. Not only is the epiphyseal region affected,
but the bones themselves in rachitic children show
a decreased mineral content. Moderate hyper-
vitaminosis D will increase absorption of calcium,
producing a mild hypercalcemia and increased cal-
cification of growing bone. Calcium deposits may
occur even in soft tissues such as kidney and
arterial walls. In cases of marked overdosage,
secondary toxic effects occur. One can note resorp-
tion of bone similar to that seen in hyperpara-
thyroidism, and poor calcification of new bone — a
condition described as “hypervitaminosis D rick-
ets.”

The influence of various hormones on bone has
been extensively studied, but with equivocal re-
sults. Estrogen has a pronounced effect on bone
formation in the experimental animal, but similar
effects have not been found in man. In the clinical
condition of osteoporosis, where there is usually a
generalized atrophy of the skelton in the post-men-
opausal female, administration of estrogen and
androgen has been found effective in relieving
pain, but there is no associated increase in bone
density.

Administration of adrenal cortical steroids or
associated compounds produces osteoporosis. The
hormone interferes with the formation of ground
substance and, consequently, with the formation
of new bone, while absorption continues at a nor-
mal rate. Fractures may occur. The same effect
results from administration of ACTH.

BONE AND RADIATION

Much attention has been given in recent years
to the effect of radiation upon bone. This has
been stimulated in part by nuclear research and
by the availability of radioactive isotopes for use
in diagnosing and treating various disorders.

Radioactive materials have been used in small
amounts for tracer studies of bone since the intro-
duction of P32 in 1935. Isotopes are administered
as the ions themselves or in combination with
various organic compounds having a specific phys-
iologic activity. The commonly used isotopes are
Ca,45 Sr,85 P32 and C,14 and they are chosen be-
cause of their short half-lives, which make their
influence on bone metabolism negligible.

144

Journal of Iowa Medical Society

March, 1962

Nuclear fission produces radioactive isotopes
of 34 elements. Of these, 14 remain significantly
active after a week, but only one, Sr,90 is present
in large enough amounts and is absorbed to such
a degree as to be of clinical significance. Once in
the serum, Sr90 will substitute for calcium in the
crystal lattice of bone and will remain for periods
exceeding a year.

The effect of internal radiation on bone depends
more on the concentration and distribution of the
element than on the type of radiation emitted.
Although bone is relatively radioresistant, a cer-
tain amount of necrosis is produced by elements
such as radium and strontium, which persist for
years within the bone crystal. Follow-up studies
on watch-dial painters who had ingested toxic
amounts of radium have provided the best infor-
mation on long-term effects of internal irradiation.
A frequent finding was necrosis of the mandible
and maxilla, and necrosis to a lesser extent in
other bones, leading to pathologic fractures. A
more serious complication was the induction of
malignant tumors, usually osteogenic sarcomas,
after a latent period of 12 to 30 years. Attempts
to promote removal of these isotopes have in-
cluded administration of citrate to increase the
solubility of bone, parathyroid to increase resorp-
tion, and non-toxic elements to compete with the
isotopes for a place in the crystal. So far, a slight
increase in excretion has not been sufficient to
modify the long-range effects of the radioactive
element.

CONCLUSION

Many problems remain to be solved in the field
of bone disease. Osteoporosis as a clinical entity in
the older age group has been increasing and yet
little is known about the pathogenesis. Scoliosis
has many causes but the majority of cases are
idiopathic. Paget’s disease may affect three per
cent of persons over 40 and the actual cause is un-

Parkinsonism Article

Evidence that parkinsonism can be inherited as
a dominant trait was reported in the February 3
issue of j.a.m.a. by Dr. George G. Spellman, of
Sioux City. He said that the occurrence of the dis-
ease in a 36-year-old woman had been traced to
her great-grandfather.

The great-grandfather had had eight children,
three of whom definitely had the disease. One of
those was the patient’s grandmother, three of
whose children (including the patient’s mother)
developed it. The patient was the first of the nine
in her sibling group to manifest it, but later a
younger brother was stricken. The incidence of
parkinsonism in that family is so high that it

known. While fractures occur as the result of
trauma, the fact that they occur in characteristic
sites according to age remains unexplained. Rick-
ets has largely been controlled but a special group
of Vitamin D resistant cases is stimulating further
studies on Vitamin D and calcium metabolism.
These are just a few examples and represent areas
where much of the current research is being di-
rected. The ultimate solution to these problems
will depend upon more basic knowledge of the
physiology and natural aging process of bone.

ACKNOWLEDGEMENT

I wish to thank Dr. I. V. Ponseti of the Ortho-
pedic Department, State University of Iowa, for
his helpful comments during the preparation of
this paper.

REFERENCES

1. McLean, F. C., and Urist, M. R.: Bone, Second Edition.
Chicago, University of Chicago Press, 1961.

2. Bourne, Geoffrey, H., ed.: The Biochemistry and Physi-
ology of Bone. New York, Academic Press, Inc., 1956.

3. Glimcher, Melvin J.: Specificity of the Molecular Struc-
ture of Organic Matrices in Mineralization. In: The Biochem-
istry and Physiology of Bone. Washington, D. C., AAAS, 1960.

4. Neuman, W. F., and Neuman, M. W.: Recent advances
in bone growth and nutrition. Borden Rev. Nutr. Res., 21:37-
60, (Jul.-Aug.) 1960.

5. Robinson, R. A., and Watson, M. L.: Collagen-crystal
relationships in bone as seen in electron microscope. Anat.
Rec., 114:383-409, (Nov.) 1952.

6. Trueta, J., and Morgan, J. D.: Vascular contribution to
osteogenesis: I. Studies by injection method. J. Bone & Joint
Surg., 42B:97-109, (Feb.) 1960.

7. Trueta, J., and Amato, V. P.: Vascular contribution to
osteogenesis: III. Changes in growth cartilage caused by
experimentally induced ischemia. J. Bone & Joint Surg.,
42B:571-587, (Aug.) 1960.

8. Greville, N. R., and Janes, J. M.: Experimental study of
overgrowth of fractures. Surg., Gynec. & Obst., 105:717-721,
(Dec.) 1957.

9. Barr, J. S., Lingley, J. R., and Gall, E. A.: Effect of
roentgen irradiation on epiphyseal growth. Am. J. Roentgenol.,
49:104-115, (Jan.) 1943.

10. Strobino, L. J., French, G. O., and Colonna, P. C.: Effect
of increasing tensions on growth of epiphyseal bone. Surg.,
Gynec. & Obst., 95:694-700, (Dec.) 1952.

11. Brues, A. M.: Biological hazards and toxicity of radio-
active isotopes. J. Clin. Investigation, 28:1286-1296, (Nov.
pt. I) 1949.

12. Aub, J. C., Evans, R. D., Hempelmann, L. H., and
Martland, H. S.: Late effects of internally-deposited radio-
active materials in man. Medicine, 31:221-329, (Sept.) 1952.

by Sioux City Doctor

suggests a dominant characteristic — one that can
be handed down in a gene from only one parent —
Dr. Spellman said.

Some researchers have shown that the disease
can be inherited as a recessive trait — i.e., inherit-
able only if both parents have the gene. Only one
other investigator, he said, has produced evidence
indicating that the trait behaves as a dominant
characteristic.

The cause of the disease has not been estab-
lished, but heredity has been regarded as one of
the etiologic factors, since familial patterns have
been noted in from five to 16 per cent of cases.

Unexplained Hemorrhage
During Pregnancy

GEORGE G. SPELLMAN, M.D.

Sioux City

Bleeding tendencies during pregnancy are not un-
usual. As our knowledge of the clotting mechan-
ism has increased, we have become able, in most
instances, to determine the cause. Hypofibrino-
genemia due to premature separation of the pla-
centa, amniotic-fluid embolism, or intrauterine
retention of a dead fetus are probably the most
frequent etiologies.1 Blood incompatibility of the
ABO system or the Rh system in the maternal and
fetal circulations may cause a lowering of the
fibrinogen levels in the mother.2 Thrombocytopenia
may occur, especially in the presence of pre-
eclampsia, and this may be associated with hemor-
rhage.3 Unusual bleeding during pregnancy caused
by hypoprothrombinemia and hypoproconverti-
nemia has been reported.4 This coagulation defect
may respond to intravenous vitamin K, but may
not respond to oral vitamin K. Pre-eclampsia and
eclampsia without thrombocytopenia frequently
cause hemostatic defects, including prolongation
of the clotting time of mixtures of thrombin and
oxalated plasma.1'1 Rare causes of bleeding during
pregnancy include abortion, thrombocytopenic
purpura, and the appearance of circulating anti-
coagulants.

Apparently, there are still other causes. In the
following case, the cause of the bleeding tendency
was not found, although every effort was made to
determine it. A report of this case seems war-
ranted, since it will demonstrate that there still
are factors in the hemorrhagic tendency that are
unknown.

CASE REPORT

The 41-year-old wife of a physician was gravida
six and para five. She was in the eighth month of
her pregnancy when she was admitted to the hos-
pital on March 18, 1959, with a history of inter-
mittent epistaxis for 48 hours. She had been bleed-
ing quite profusely from the nose since 10: 00 p.m.
the preceding evening. She reached the hospital at
3:00 a.m., and nasal packs were inserted. These
failed to control the bleeding and she continued to
have oozing around the packs.

Her hemoglobin at the time of admission was
8.8 Gm. Her bleeding time was 2 min. 16 sec., her
coagulation time was 5 min. 30 sec., and her plate-
let count was 720,000. Her prothrombin time was
15 sec., and the control was 12 sec. A test for

fibrinogen was normal, and a test for fibrinolysins
was negative. Her red blood cell fragility was
normal, with hemolysis beginning at .38 and being
completed at .36. The control began at .40 and
was complete at .32. Clot retraction was complete
in two hours. A test for Bence Jones protein was
negative. A urinalysis was normal.

The patient continued to bleed in spite of the
packing, and the bleeding was so profuse that it
pushed the packing out. She was given vitamin K,
vitamin C, Premarin intravenously, Adrenosem
intramuscularly, and Koagamin intramuscularly.
She received transfusions of 16 pints of blood.

The consensus of the obstetrical consultants in
Sioux City was that an induction of labor was not
indicated, and that the pregnancy had little to do
with the patient’s bleeding tendency. Telephone
consultations were also held with Dr. W. C.
Keettel, head of obstetrics at the State University
of Iowa, and it was his feeling too that the preg-
nancy was coincidental and not the cause of
bleeding.

On the second day after the patient’s admission,
the bleeding was still uncontrolled. The blood was
coming from the left nares. The left external carot-
id artery was ligated, but that procedure failed
to control the bleeding.

A telephone consultation was held with Dr.
Jack Carter, who now is head of pathology at the
University of Kansas, but at that time was on the
S.U.I. staff, and blood was sent to him for further
tests. His results were as follows:

One-stage prothrombin 100%

Two-stage prothrombin 92%

Accelerator activity . . . 100%

Fibrinogen Normal

Fibrinolysins None

Recalcified clotting time 1 min., 10 sec.

(normal = IV2 to 2% min.)

Stypfen time 8 sec.

(normal = 16-18 sec.)

Dr. Carter felt that these tests failed to demon-
strate the cause of the patient’s bleeding. Even be-
fore completing those tests, he had forwarded
some vitamin KS2 to us. KS2 is a special substance
to which one case of hemorrhagic tendency in
pregnancy had responded. We gave it to our pa-
tient on March 21, 1959, and temporarily the bleed-
ing seemed to decrease.

On March 23, the patient passed some black
stools. It was thought that they might have oc-
curred as a result of swallowing blood, although
she had been expectorating most of the blood that

145

blood pressure approaches normal
more readily, more safely.... simply

(hydroflumethiazide, reserpine, protoveratrine A-antihypertensive formulation)

Early, efficient reduction of blood pressure. Only Salutensin combines
the advantages of protoveratrine A (“the most physiologic, hemody-
namic reversal of hypertension”1) with the basic benefits of thiazide-
rauwolfia therapy. The potentiating/additive effects of these agents2-8
provide increased antihypertensive control at dosage levels which
reduce the incidence and severity of unwanted effects.

Supplied: Bottles of 60 scored tablets.

References: 1. Fries, E. D.: In Hypertension, ed. by J. H. Moyer, Saunders, Phila., 1959 p. 123.
2. Fries, E. D.: South M. J. 51:1281 (Oct.) 1958. 3. Finnerty, F. A. and Buchholz, J. H.: GP 17:95
(Feb.) 1958. 4. Gill, R. J., et al.: Am. Pract. & Digest Treat. 11:1007 (Dec.) 1960. 5. Brest, A. N.
and Moyer, J. H.: J. South Carolina M. A. 56:171 (May) 1960. 6. Wilkins R. W.: Postgrad. Med.
26:59 (July) 1959. 7. Gifford, R. W., Jr.: Read at the Hahnemann Symp. on Hypertension, Phila.
Dec. 8 to 13, 1958. 8. Fries, E. D., et al.: J. A. M. A. 166:137 (Jan. 11) 1958. 9. Ford, R. V. and
Nickel I , J.: Ant. Med. &. Clin. Ther. 6:461, 1959.

all the antihypertensive benefits of thiazide-
rauwolfia therapy plus the specific,
physiologic vasodilation of protoveratrine A

11 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS BY SERIAL ADDITION OF
THE INGREDIENTS IN SALUTENSIN IN A TEST CASE

(Adapted from Spiotta, E. J.: Report to Department of Clinical Investigation, Bristol Laboratories)

SALUTENSIN

Hg.

190

180

170

160

150

140

130

120

110

100

thiazide

protoveratrine A

■nuw«

(thiazide
protoveratrine A
reserpine)

thiazide

SYSTCLIC

JAN. FEB. MARCH

12 19 27 3 10 17 24 2 9 17 23 30

3V2 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS USING SALUTENSIN FROM
THE START OF THERAPY IN A “DOUBLE BLIND” CROSSOVER STUDY

Mean Blood Pressures-Systolic (S) and Diastolic (D)

Placebo Followed by Salutensin
(22 patients)

Salutensin Followed by Placebo
(23 patients)

Placebo
Before After

Salutensin
Before After

Placebo
Before After

\{ aRisToiT

BRISTOL LABORATORIES/Div.of Bristol-Myers Co., Syracuse, N.Y.

148

Journal of Iowa Medical Society

March, 1962

came down her posterior pharynx. A urinalysis
on that day showed no red cells, but a repeat
urinalysis on the next day revealed many of them.
Shortly thereafter, the urine became grossly
bloody.

In view of the development of this generalized
bleeding tendency, we felt that delivery was im-
perative to save the lives of the patient and the
baby. The mother’s condition was good, and the
baby was in good condition. The patient had de-
veloped some hives after one of the transfusions.

The obstetricians agreed that delivery was indi-
cated, and felt that cesarean section was the
method of choice, since the cervix was not dilated,
and was very thick. The patient was prepared for
surgery, and the section was performed at 8:00
p.m. on March 24.

The change in the patient was remarkable and
immediate. She had no more bleeding what-
soever, and on the next morning there was a firm,
dark clot in the posterior pharynx. The urine was
normal in color, and there were only a few red
cells in it. After a few days, the stools were no
longer tarry. The patient had a prompt and un-
eventful recovery.

The baby did have some difficulty a few days
later, although he had been fine at the time of
delivery. The pediatricians diagnosed a hilar mem-
brane. He responded to treatment and was able
to go home soon after his mother. The mother was
discharged on April 1, 1959, in excellent condition.
Since then, she has had no bleeding and has been
perfectly healthy.

COMMENT

This is a case of hemorrhagic tendency that de-
veloped during pregnancy. It was impossible, by
laboratory means, to demonstrate any abnormali-
ties in the clotting mechanism. The obstetricians
regarded the bleeding as coincidental with the
pregnancy, rather than as resulting from it. The
bleeding continued, and the patient developed a
generalized bleeding tendency. The improvement
after delivery was prompt, and the bleeding tend-
ency ceased.

None of the usual causes were present. The pa-
tient had no toxemia of pregnancy. Her blood
pressure and urine had been normal throughout
the pregnancy. After delivery, the placenta was
examined very carefully, but there was no pre-
mature separation or other abnormality of the
placenta or products of conception. Though every
possible effort was made to determine the cause
of the bleeding, none was found. Every medica-
tion that might even remotely affect bleeding had
been utilized to no avail.

The cessation of bleeding after delivery was
so dramatic that all of the physicians felt there
must have been a cause-effect relationship between
the patient’s pregnancy and her bleeding. That
factor — whatever it was — disappeared within a
few hours after delivery.

SUMMARY

In the case that has been presented, hemorrhage
occurred during pregnancy, and the cause could
not be found, despite diligent and exhaustive ex-
aminations. The hemorrhagic state ceased prompt-
ly upon delivery of the baby by cesarean section.

It is possible that the hemorrhagic state may
have been due to some circulating factor arising
from the pregnancy.

The pregnancy was normal in all other respects.
The baby had a stormy course, beginning a few
hours after delivery, but is well and healthy to-
day, as is his mother.

REFERENCES

1. (a) Ratnoff, O. D., Pritchard, J. A., and Colopy, J. E.:
Medical progress; hemorrhagic states during pregnancy.
New England J. Med., 2 5 3:63-69, (Jul. 14) and 97-102, (Jul.
21), 1955.

(b) Hartmann, R. C., and McGanity, W. J.: Fibrinogen
deficiency in pregnancy; report of unusual case. Obst. &
Gynec., 9:466-471, (Apr.) 1957.

(c) Weiner, A., Reid, D. E., and Roby, C. C.: Coagulation
defects associated with premature separation of normally
implanted placenta. Am. J. Obst. & Gynec. 60:379-386, (Aug.)
1950.

(d) Ratnoff, O. D., Lauster, C. F., Sholl, J. G., and Schil-
ling, M. O.: Hemorrhagic state during pregnancy with

presence of maternal Rh antibodies, death of fetus and
hypofibrinogenemia. Am. J. Med., 13:111-120, (Jul.) 1952.

2. Reilly, C. T., and Zito, A. J.: Hypofibrinogenemia and
ABO heterospecific pregnancy; preliminary report. Am. J.
Obst. & Gynec., 77:375-381, (Feb.) 1959.

3. Ferguson, J. H.: Platelet decrease and disappearance
in obstetric conditions. Am. J. Obst. & Gynec., 72:1315-
1318, (Dec.) 1956.

4. (a) Setna, S. S., and Altman, S. J.: Unusual bleeding
during pregnancy; report of case due to hypoprothrombi-
nemia and hypoproconvertinemia. Blood, 11:430-435, (May)
1956.

(b) Hill, J. M., Speer, R. J., Roberts, A., and Malonev, M.:
Hypoprothrombinemia and hypoproconvertinemia during
pregnancy. J. Lab. & Clin. Med., 45:308-312, (Feb.) 1955.

The Management of Trauma

A three-day postgraduate course on the man-
agement of trauma is to be presented on March
7-9 at the University of Colorado Medical Center,
in Denver, with the Colorado Committee on Trau-
ma of the American College of Surgeons as a co-
sponsor. It will provide a broad review of the
traumatic problems commonly met in the civilian
population.

A faculty of 80 Colorado physicians will be
joined by two guest teachers, Dr. Edwin F. Cave,
a consulting and visiting orthopedic surgeon at
Massachusetts General Hospital and a faculty
member at Harvard, and Dr. Preston A. Wade, a
professor of clinical surgery at the Cornell Uni-
versity Medical College and a past-chairman of
the Trauma Committee of the American College
of Surgeons.

In the selection of subjects to be reviewed in
the course, emphasis has been placed upon basic
physiologic processes that allow an understanding
of the pathology and abnormal physiology result-
ing from trauma. The eight simultaneous small
group clinics to be held on two mornings will al-
low consideration and demonstration of practical
aspects of patient care, discussion of cases, and re-
view of the material presented in the more formal
parts of the program.

State University of Iowa
College of Medicine

Clinical Pathologic Conference

SUMMARY OF CLINICAL FINDINGS

A 40-year-old, married teacher was referred to
this hospital in September, 1957, for pulmonary-
function studies because an abnormal chest x-ray
had suggested pulmonary fibrosis. He had had
episodes of tachycardia for 20 years that started
and ended abruptly. Ten years before his admis-
sion, clubbing of the fingers had been noted, but
a chest x-ray had been normal.

The patient’s blood pressure was 120/80 mm. Hg,
his pulse rate was 80/min., and his respiratory rate
was 20/min. His physical examination was normal
except for clubbing of his fingers. The hemoglobin
was 12 Gm./lOO ml., and the white blood cell count
was 12,950/cu. mm. A chest x-ray showed finely
nodular densities throughout both lung fields.
Pulmonary-function studies revealed normal ar-
terial oxygen saturation and CO... The vital ca-
pacity was 3.9 L., or 77 per cent of predicted nor-
mal. The residual volume was 1.7 L., or 108 per
cent of predicted normal. The distribution of in-
spired air was slightly uneven. The maximal
breathing capacity was 105 L./min. The diffusing
capacity was 17 ml. /min., or 60 per cent of pre-
dicted normal. The patient was feeling well. No
medication was given, and he returned to full-
time work.

During the following 2M> years, he was examined
three times, but no change was found in his con-
dition. In February, 1960, his hemoglobin was
found to be 9.5 Gm./lOO ml. His urine and stool
were negative for blood. X-rays of the esophagus,
stomach, duodenum and colon were normal.

During March and April, 1960, he developed
night sweats and migratory arthritis involving
both feet, the right hand and the left elbow. The
pain was so severe that he had to be on crutches
much of the time. He was treated with aspirin, and
was urged to continue his work. In July, he was
unchanged, clinically. The urinalysis was negative,
the hemoglobin was 11 Gm./lOO ml., and the white
blood cell count was 7,150/cu. mm., with 56 per
cent polymorphonuclear leukocytes, 2 per cent
eosinophils, 1 per cent basophils, 39 per cent
lymphocytes and 2 per cent monocytes. The red
blood cell count was 2,990,000/cu. mm., the hemat-

ocrit was 30 per cent, the platelet count was 100,-
000, and the reticulocyte count was 3 per cent. The
latex and the bentonite agglutination tests were
negative. The erythrocyte sedimentation rate was
99 mm. /hr. He was treated with 10 mg. of predni-
sone per day, and his symptoms improved.

In November, 1960, he was having drenching
night sweats, a non-productive cough, vocal hoarse-
ness, and continued difficulty with his joints. His
hemoglobin was 9.5 Gm./lOO ml., and his white
blood cell count was 5,600/cu. mm. Posteroanterior
and lateral films of his chest showed no change in
the pulmonary lesion. Pulmonary-function studies
produced results similar to those of September,
1957. A bone marow was very cellular. There was
erythroid hyperplasia, with anisocytosis, polychro-
masia and stippling of the red blood cells. The
myeloid elements were plentiful, and showed a
slight shift to the left and an increase in the baso-
phils. The megakaryocytes were adequate in num-
ber, but the platelets were diminished. The pa-
tient’s total bilirubin was 0.6 mg. per cent, his
cholesterol 186 mg. per cent, and his uric acid 4.1
mg. per cent. A lupus erythematosus preparation
was negative. Serum iron was 87 micrograms per
cent, and total serum protein 7.4, albumin 4.1, and
globulin 3.3 Gm. The red blood cell half-time sur-
vival was 21.5 days. Normal uptakes were demon-
strated over the liver and spleen following a radio-
active chromium study. The direct and indirect
Coombs tests were negative. The fragility test
showed that hemolysis began at .44 and was com-
plete at .28. A gastrocnemius muscle biopsy showed
normal skeletal muscle.

Prednisone was increased to 60 mg. per day, and
thereafter the patient felt very much better. He
was able to continue teaching. In December, three
sputum smears for acid-fast bacilli were negative.
The sputum was cultured for tuberculosis and
was negative, and guinea pig inoculations were
likewise negative. By mid-January, however, he
was in trouble again, with weakness, joint pain
and difficulty in sleeping.

His symptoms continued into February. He was
unable to work. On February 13, 1961, he returned
to the hospital because of pain in the sternum and

149

150

Journal of Iowa Medical Society

March, 1962

difficulty in swallowing. A physical examination
showed no change. The hemoglobin was 9 Gm./lOO
ml., the white blood cell count was 14,000/cu. mm.,
and there were 2 per cent bands, 42 per cent seg-
mented polymorphonuclear leukocytes, 44 per
cent lymphocytes, 3 per cent monocytes, 6 per cent
nucleated red blood cells and 3 per cent normo-
blasts.

On February 19, a striking number of petechial
hemorrhages appeared throughout his skin, and
he developed epistaxis. On February 22, the hemo-
globin was 6.8 Gm./lOO ml., and the white count
was 43,000/cu. mm. He got progressively worse,
and died on February 24.

SUMMARY OF CLINICAL DISCUSSION

Dr. George N. Bedell, Internal Medicine: Mr.
James Auer will discuss the case for the medical
students.

Mr. James Auer, junior ward clerk: The student
discussion for this CPC has been prepared by the
junior ward clerks of Ward C-31, the others of
whom are Mary Jane Adams, James Addy, Roger
Atkins and Cass Bailey.

In September, 1957, the patient appears to have
had a chronic illness of his respiratory system, in-
dicated by clubbing of the fingers, the roentgeno-
grams and the pulmonary function tests. These
suggested a decrease in the area available for
gaseous exchange. The finely nodular densities
throughout both lung fields suggest the following
possibilities: miliary tuberculosis, sarcoidosis, idio-
pathic pulmonary hemosiderosis, pneumoconiosis,
fungus disease and lymphangitic carcinomatosis.
Beginning the process of inductive reasoning, one
can discard miliary tuberculosis and lymphangitic
carcinomatosis on the grounds of the subsequent
duration of the illness. The patient’s occupation
would tend to rule out pneumoconiosis. Histo-
plasmosis and coccidioidomycosis skin tests were
found to be negative. Thus, we are left to consider
only sarcoidosis and idiopathic pulmonary hemo-
siderosis. We shall come back to these a little later.

The patient’s migratory arthritis, which may
actually be an arthralgia, brings to mind such dis-
eases as lupus erythematosus, polyarteritis, hyper-
trophic osteoarthropathy, dermatomyositis, rheu-
matoid arthritis and rheumatic fever. Lupus was
ruled out by a negative lupus erythematosus prep-
aration. Polyarteritis and dermatomyositis were
ruled out by a muscle biopsy. The latex test was
performed to rule out rheumatoid arthritis. In re-
gard to hypertrophic osteoarthropathy, we should
have liked to see x-rays of the patient’s Rubbed
fingers and affected joint, but we understand that
films were not taken of those areas at the time
when they first were noted. We are ruling out
rheumatic fever because the patient seems not to
have had a previous streptococcal infection, and
because he had no observable cardiac involvement
during the remainder of his life.

A steadily decreasing hemoglobin, in the face
of erythroid hyperplasia and without blood loss in
the stool or urine, and a half-time red blood cell
survival rate of 21.5 days strongly suggest an in-
creased rate of red-cell breakdown in the body. As
noted in the protocol, radioactive chromium up-
take studies over the liver and spleen showed that
those organs were not the site of this destruction.
Physical examination showed no abnormality of
the liver or spleen.

Now, let’s go back to the pulmonary densities
noted on x-ray. Two conditions, sarcoidosis and
idiopathic pulmonary hemosiderosis, were not
ruled out. In view of the patient’s migratory arthri-
tis or arthralgia, hypertrophic osteoarthropathy
remains to be dealt with. His anemia problem in-
dicates an as yet unknown source of red-cell de-
struction and/or loss.

These three conditions — anemia, pulmonary nod-
ular densities and hypertrophic osteoarthropathy —
seem interrelated. Sarcoidosis does not fit the pat-
tern.

The account that we have been given of the
period immediately preceding this man’s death is
rather vague and confusing. From the informa-
tion contained in the protocol, it appears that the
immediate cause of death was probably a com-
bination of elements, i.e., toxicity from chronic
illness of at least 41 months, and a possible pneu-
monia with septicemia, which may have been en-
hanced by the high and prolonged dosages of
prednisone.

Our diagnosis is idiopathic pulmonary hemo-
siderosis, with hypertrophic pulmonary osteoar-
thropathy.

Dr. Richard D. Eckhardt, Internal Medicine,
Iowa City VA Hospital: I appear before you most
humbly today, especially since I am utterly con-
fused about the nature of this patient’s illness.
Usually, I find the junior students’ discussion ex-
tremely helpful, but today my diagnosis differs
from theirs, and our disagreement makes me even
less sure of myself.

The patient is a 40-year-old man who is known
to have had paroxysmal tachycardia for 20 years,
prominent clubbing of the fingers for 10 years,
pulmonary changes — presumably of a fibrotic and
restrictive sort — for fewer than 10 but more than
three years, and a severe, crippling arthritis as-
sociated with fever and anemia for approximately
one year. The anemia may have existed for as long
as three years. The final episode of his illness was
characterized by a severe hemorrhagic phenom-
enon, marked leukocytosis and death.

I find it most difficult to fit these all neatly to-
gether, and it seems that it would be acceptable to
make several diagnoses. Nevertheless, I shall talk
about several illnesses and see whether I can
reasonably arrive at one all-inclusive diagnosis.

Paroxysmal tachycardia often occurs in the ab-
sence of organic heart disease. This aspect of the

Vol. LII, No. 3

Journal of Iowa Medical Society

151

patient’s difficulties was noted when he first sought
medical attention, but then wasn’t accorded very
great consideration until three or four years before
he died. The myocardium may be involved in
several of the diseases that I shall mention pres-
ently, but there was no evidence of valvular heart
disease, of severe or progressive myocardial dis-
ease, or of heart failure.

I find it perplexing to attempt a rational ex-
planation of the clubbing of this patient’s fingers.
There seems to be do doubt that clubbing was
present, and had been for several years. In fact,
it had caused enough concern, ten years earlier, so
that a chest x-ray was done. That film was in-
terpreted as normal. Clubbing can be congenital.
Dr. Bean has reported an unusual form of it that
is seen in packing-house workers who pull hides
off cattle. The workers’ thumbs are spared this
deformity. It is doubtful, however, that today’s
patient had either the congenital or the packing-
house worker’s acquired form of clubbing. Further-
more, he didn’t have congenital cyanotic heart
disease. Perhaps the most logical explanation for
clubbed fingers in a middle-aged patient with x-ray
evidence of pulmonary fibrosis would be bron-
chiectasis, yet there were no symptoms that might
suggest active disease of that sort.

At this stage in the discussion, I should like to
ask Dr. Gillies to give us his impressions of the
x-rays.

Dr. Carl L. Gillies, Radiology: The first film of
the chest was obtained in 1952 and was thought to
be negative. In the second film, obtained in 1958,
there appeared to be a diffuse fibrosis in both
lungs. The third film, in November, 1960, showed a
slight but definite increase in the amount of
fibrosis. The fourth film, obtained only two months
later, in late January, 1961, showed very little
progression in the amount of fibrosis. The heart
was not enlarged. We could see no evidence of
bronchiectasis. As far as we were concerned, the
diagnosis was diffuse but idiopathic fibrosis of the
lung — not very pronounced, but nevertheless defi-
nite.

Dr. Eckhardt: I gather that you have no x-rays
of the bones, Dr. Gillies.

Dr. Gillies: We have none.

Dr. Eckhardt: Thus, the x-ray findings were con-
sistent with pulmonary fibrosis. I think the lung-
function tests suggest some degree of restricting
ventilatory disease of the lungs, fitting the broad
category of alveolar capillary block. This was not
marked. The patient was not cyanotic. His pul-
monary disability presumably didn’t progress
markedly during a three-year period of observa-
tion.

At this time, it is necessary to attempt defining
this patient’s chronic pulmonary fibrotic disease.
As I said, although bronchiectasis must be con-
sidered, I don’t think we have much to support
that diagnosis. However, one is sometimes sur-

prised to find evidence, at autopsy, of considerable
bronchiectasis of a congenital nature that hadn’t
been suspected clinically. Production of large
amounts of foul-smelling sputum need not be pres-
ent in uncomplicated bronchiectasis. There is very
little in the patient’s history to support a diagnosis
of chronic lung disease of an infectious type. Con-
cern was evidenced about the possibility of tuber-
culosis, but sputum cultures were negative.

Several illnesses that can involve the lungs are
characterized as diffuse, disseminated, nonlipoid
reticuloendothelioses.1 These have been grouped
by Lichtenstein under the term “histocytosis X.”
They include eosinophilic granuloma, Letterer-
Siwe disease and Hand-Schiiller Christian disease.
I believe these conditions are sufficiently non-
specific so that a lung biopsy would be requisite in
determining the proper diagnosis. The same would
hold true for the various forms of fibrosing inter-
stitial pneumonitis described by Hamman and
Rich.2 Another group of diseases, which Fienberg
has called pathergic granulomatoses,3 presumably
are due to altered tissue reactivity. Loffler’s syn-
drome fits into this grouping, as does Wegener’s
granulomatosis, polyarteritis nodosa, systemic
lupus erythematosus and other forms of allergic
angiitis. Again, I would need a lung biopsy, or
findings in addition to those mentioned in the
protocol, if I were to diagnose one of those ill-
nesses.

Pulmonary hemosiderosis was mentioned by the
junior students, and must be considered in the
differential diagnosis. Obviously this man’s blood
was given a “million-dollar work up.” As you
know, Drs. Hamilton and Sheets have done some
excellent work demonstrating that one of the
major factors responsible for the anemia of pri-
mary (idiopathic) pulmonary hemosiderosis is
hemolysis of blood cells. The studies on this man
were sufficient to suggest that there was a degree
of hemolysis of his blood. However, the cases that
I have read about — and these have included those
of Hamilton and Sheets — all have had hemoptysis.
The hemoptysis need not be very prominent, but it
should occur, at least to a limited extent. Further-
more, I am unable to find any descriptions in the
literature of patients with pulmonary hemosid-
erosis associated with crippling arthritis. Thus, I
cannot find sufficient data to support this intri-
guing diagnosis.

Prior to the last year of his life, the patient had
no difficulties other than a few attacks of paroxys-
mal tachycardia and the pulmonary pathology that
was investigated. Then, he suffered from a crip-
pling migratory polyarthritis, and had to walk with
crutches. I gather that the physicians who saw him
thought, initially, that he had rheumatoid arthri-
tis. They gave him some aspirin and said, “Keep
active; don’t give up!” But it was evident after just
a couple of months that he needed something more.

152

Journal of Iowa Medical Society

March, 1962

He was given cortisone-like drugs, and these were
continued until his death.

I have thought that sarcoidosis must be con-
sidered seriously in this man. There are reports in
the literature describing individuals with sarcoi-
dosis with polyarthritis that appeared classical for
rheumatoid arthritis. Certain of these patients
evidenced improvement when they were given
steroids. Thus, I am sure that the migratory poly-
arthritis seen in this man could be consistent with
that seen in association with Boeck’s sarcoid.
Nevertheless, this is fairly rare. Anemia is also
seen in sarcoidosis. Its etiology is unknown, al-
though it is often explained on the basis of hyper-
splenism. In this man, the spleen was not described
as enlarged. Clubbing is seen in Boeck’s sarcoid,
but only occasionally. Against this diagnosis are
the patient’s normal serum globulin and normal
serum calcium. Most patients with pulmonary in-
volvement from sarcoid have hilar adenopathy.
This man did not. For these many reasons, I am
skeptical of the diagnosis of Boeck’s sarcoid. It is
possible, and I wouldn’t be surprised to hear Dr.
Stamler say so, but it would not be my first diag-
nosis.

This man had an illness that seemed primarily to
bother his joints, and from the description we have
been given of it, I think we should say that he had
rheumatoid arthritis. There seems to be absolutely
nothing wrong with that as a clinical diagnosis.
The patient experienced a rather poor response to
salicylates, but a fairly good response to steroids.
His arthritis smoldered along, first getting better
and then worse. With a further increase in the
steroid dosage, the arthritis again improved. Sys-
temic lupus erythematosus also should be con-
sidered, as should scleroderma. This latter illness
seems even more likely in view of the patient’s
subsequent difficulty in swallowing. Thus, I think
one of the collagen vascular diseases must be very
seriously considered as responsible for his ar-
thritic complaints.

Now, is it possible to reconcile pulmonary
fibrosis with a collagen vascular disorder? I think
so. There are articles in the literature describing
pulmonary fibrosis even without the arthritic man-
ifestations of rheumatoid arthritis. Although one
would be more comfortable diagnosing rheumatoid
arthritis if either the bentonite or the latex agglu-
tination test had been positive, it should be re-
called that these tests are negative in perhaps 20
to 25 per cent of individuals with rheumatoid
arthritis.

As I surveyed a list of various illnesses in which
anemia is associated with joint disease. I ran
across another condition that I think should be
mentioned. It is rare, and perhaps I’m altogether
out of line in mentioning it, but I shall. It is amy-
loidosis.4 I am thinking chiefly of primary, sys-
temic amyloidosis, although there is a possibility
of its being secondary to chronic lung disease.

There aren’t a great many features of this case to
support such a diagnosis, but amyloidosis can be
associated with joint trouble and with anemia. The
few individuals whom I have seen with primary
systemic amyloidosis have been mainly those
whom Dr. Maurice VanAllen has studied, and they
have had neurologic manifestations. This patient
had none, but they need not be present. Amyloi-
dosis could conceivably explain the patient’s par-
oxysmal tachycardia on the basis of cardiac in-
volvement. Furthermore, the patient’s terminal
episode could be accounted for on this basis, since
involvement of blood vessels and marked purpuric
or hemorrhagic phenomena are very frequently
seen as a terminal event in that particular illness.
I don’t regard primary systemic amyloidosis as a
very reasonable diagnosis, but it is a possible one.

Another possible explanation for the terminal
hemorrhagic disturbance might be that the pa-
tient was having difficulty in forming platelets.
This phenomenon has been observed in patients
receiving very large doses of steroids. Whether
this difficulty was present. I do not know.

I can’t adequately explain the patient’s terminal
picture. I am particularly disturbed about his
sternal chest pain, which certainly makes one
think of leukemia. From the data available in the
protocol, I would have to assume that his terminal
bleeding episode perhaps was related to an over-
whelming infection, or perhaps related to his large
doses of steroids.

In summary, I think this gentleman’s disease in-
volving his lungs and his joints, and associated
with a mild hemolytic anemia, was probably a
systemic illness. My first choice would be to place
it in the group of collagen vascular diseases, prob-
ably in the rheumatoid arthritis group. However,
I think it isn’t possible to rule out scleroderma,
or to be completely sure that we aren’t dealing
with systemic lupus erythematosus. I think that
Boeck’s sarcoid might be a reasonable explanation
of all the findings. It is intriguing to consider the
remote possibility that primary systemic amy-
loidosis will be found. I don’t think that this man
had an infectious process such as disseminated
tuberculosis or histoplasmosis, but again I don’t
feel that we have sufficient evidence to rule this
out.

Dr. Bedell: Dr. Eckhardt has quite adequately
summarized the clinical impressions that occurred
to those of us who attended the patient. We went
through the same thought processes, and our
clinical diagnosis was a collagen vascular disease.
We thought that it probably was rheumatoid ar-
thritis with pulmonary involvement and anemia.

There were a number of things that we were
concerned about. Lupus erythematosus was one of
them, and numerous studies were done for it —
more than are mentioned in the protocol. We were
concerned about leukemia, and bone-marrow tests
were done a number of times. We were concerned

Vol. LII, No. 3

Journal of Iowa Medical Society

153

about periarteritis, and a muscle biopsy was done.
It was negative. Thus, up until three days before
the patient died, the clinical diagnosis was very
much in doubt. Then some things happened which
made the clinical diagnosis clear. But I shall let
Dr. Stamler unveil those at the proper time.

Are there any questions?

Mr. J. W. DeGroote, senior medical student:
Aren’t these findings compatible with a diffuse
lymphoma?

Dr. Bedell: I think they well might be.

Dr. Henry E. Hamilton, Internal Medicine: In
viewing the muscle biopsy, did you see any indica-
tion that this man could have had acute thrombotic
thrombocytopenic purpura?

Dr. Bedell: That possibility was considered, but
there wasn’t anything particularly to suggest it
in terms of platelet morphology. The platelet
counts were fairly normal during much of the
time.

Dr. D. C. Funk, Internal Medicine: Was the ap-
pearance of the joints typical of rheumatoid ar-
thritis?

Dr. Bedell: No, there wasn’t really very much
to see in the joints. They were fairly normal,
though slightly red and quite painful. The patient
wasn’t inclined to exaggerate his symptoms. He
had had a great deal of difficulty with his joints,
and he did have to walk on crutches. He continued
to teach until the end of December, and indeed he
attempted to teach during part of January. Thus,
he made a real effort to keep going, but just didn’t
have the strength.

Dr. Francis Goswitz, Internal Medicine: Did he
ever have an enlarged liver or spleen?

Dr. Bedell: Not until very close to the end.

Dr. Hamilton: Did he have an accentuated pul-
monary second sound at any time? And was the
heart overactive to palpation?

Dr. Bedell: The second pulmonary sound was
normal, and the cardiac examination continued to
be normal. There was no overaccessibility or
underaccessibility. Were you wondering about evi-
dence of pulmonary hypertension, Dr. Hamilton?

Dr. Hamilton: Yes, and also about the possibility
of a fibrotic process akin to the one that one sees
in idiopathic retroperitoneal fibrosis.

Dr. Bedell: There was no evidence of pulmonary
hypertension. We considered that as a possibility.
The fibrosis in the lungs was quite definite, but
as far as we could tell, it didn’t change. We had
great difficulty in trying to decide what was caus-
ing the new symptoms that had been present for
at least a year — the anemia, the joint pains, the
fever and the chills.

Dr. Frederic W. Stamler, Pathology : At autopsy,
there were aspects of disease that correlated with
the patient’s clinical history. Chronic pulmonary
disease had been followed by a more acute condi-
tion with more generalized systemic involvement,
and possibly those two aspects of his illness had

overlapped somewhat. The patient did have rather
extensive pulmonary fibrosis that correlated well
with the x-ray findings in that it was of a very
finely nodular or lobular type. Just as there had
been very little roentgenological evidence of pro-
gression of this lesion, there was also little histo-
logic evidence of active progression of this aspect
of the disease that could be seen at the time of
autopsy. Apparently, the process had been rather
stable — an old, rather quiescent pulmonary fibro-
sis. There were also foci of myocardial fibrosis and
some old pericardial adhesions, all of which may
have been parts of the same process involving
the lungs.

The reaction of the involved lung tissue was
apparently a non-specific one. It was not a granu-
lomatous reaction, but simply a chronic fibrosing
process. Whether the corticoid therapy might have
altered it in some way, I can’t say, but I doubt
that it could have completely eliminated all evi-
dence of a more specific type of involvement.

The joints were not examined histologically at
autopsy. There was no gross indication of defor-
mity at that time. There was no evidence of a gen-
eralized systemic disease such as lupus or other
collagen vascular diseases.

Then, in addition to the old process, there was
a recent one of great significance. Terminally, this
patient had had a myelomonocytic leukemia with
extremely extensive overgrowth of the bone mar-
row and with extensive involvement of the re-
mainder of the reticuloendothelial and lymphoid
structures of the body. There was some degree of
leukemic infiltration in almost all of the organ
systems of the body. The extensive petechiae and
ecchymoses that had been noted clinically were
readily explained on the basis of platelet deficiency
associated with leukemic overgrowth of the bone
marrow.

Besides the old fibrosis, the leukemic process
had extensively involved the lungs, both by a
direct infiltration of leukemic cells and by exuda-
tion of those cells into lung alveoli. There was also
a great deal of associated pulmonary hemorrhage.
That extensive pulmonary involvement was pos-
sibly the most significant factor in the patient’s
terminal course.

Dr. William B. Bean, Internal Medicine: Can
you estimate how long that leukemia had been
going on?

Dr. Stamler: I believe the sternal marrow had
been interpreted as normal two months before the
patient’s death. In the meantime, there apparently
had been a complete shift from essentially normal
marrow and peripheral blood. At autopsy, the
bone marrow was almost completely overgrown
with leukemic cells, and the peripheral blood pic-
ture was also diagnostic of leukemia. It is diffi-
cult to accept the idea that all of this can have
happened in so short a period of time, and I won-
der how much the corticoid therapy had to do

154

Journal of Iowa Medical Society

March, 1962

with temporarily masking or suppressing the find-
ings of leukemia.

Dr. Hamilton: Back in November, I think, the
marrow was recorded here as “normal marrow,”
with questionable erythroid hyperplasia, myeloid
hyperplasia, and apparently a slight increase in the
basophils. In retrospect only, one might say that
the increase in basophils was the tip-off to the
fact that we were dealing with a leukemia, but
we could not have proved it at that time.

Dr. Bedell: It was our impression that the illness
had probably been going on for at least a year. The
anemia was an incidental finding when the patient
returned for his routine, once-a-year function
study. We know that a year earlier he had had a
normal hemoglobin. He had been anemic for a
year or longer, but for less than two years. Then
he developed these other symptoms, and it was
our clinical impression that leukemia represented
the illness which began in February and ended a
year later.

Dr. S. Shining, resident, Internal Medicine: Did
you ever do a phosphatase stain of the white blood
cells?

Dr. Bedell: Yes, that was done at one point. It
was normal, but the white blood cell count was
normal. The leukemic cells were not circulating
at the time.

We had the patient cough up sputum, and we
looked for iron in it. We were thinking of pul-
monary hemosiderosis, but we didn’t find any evi-
dence of iron in the sputum.

Dr. Bean: What was wrong with the patient’s
joints?

Dr. Bedell: I’d like to know, too. He was having
terrible pain and discomfort in his joints, but
relatively little could be found on physical exam-
ination. X-rays were not taken of the joints, and
unfortunately the joints were not examined at
postmortem.

Dr. Bean: Did he have pain in the long bones,
or just in the joints?

Dr. Bedell: Mainly in the joints, except that in
February, I think, the pain in his sternum was
probably bone-marrow pain, although he inter-
preted it as difficulty in swallowing. We got x-rays
of the esophagus, stomach and duodenum, and
they were normal. His sternum was infiltrated
with procaine, which gave some relief, and then
with cortisone, which also gave some relief.

Dr. Shining: At what point in his course did
you do the alkaline phosphatase stain?

Dr. Bedell: That was done in or about October.
In October and November, the patient had most
of those special hematologic studies. We demon-
strated that he had a hemolytic process, but we
were unable to show that cells were being clus-
tered away in any special part of the body.

STUDENTS' DIAGNOSIS

Idiopathic pulmonary hemosiderosis, with hyper-
trophic osteoarthropathy.

DISCUSSANT’S DIAGNOSIS

Collagen vascular disease, probably rheumatoid
arthritis.

ANATOMICAL DIAGNOSIS

1. Acute myelomonocytic leukemia, with wide-
spread leukemic infiltrates

2. Thrombocytopenic purpura, secondary to leu-
kemia

3. Ulceration of gastric and esophageal mucosa,
secondary to leukemic infiltrates

4. Fibrinous pericarditis with adhesions, sec-
ondary to leukemic infiltrates

5. Clubbing deformity of fingers, due to pul-
monary osteoarthropathy

6. Pulmonary emphysema and patchy fibrosis,
cause undetermined

7. Focal pneumonitis and hemorrhage, acute.

REFERENCES

1. Morton, P. H.: Chronic, disseminated, nonlipoid reticulo-
endotheliosis ( Histocytosis X): Treatment with corticotropin
and antibiotics, with report of 2 cases. Ann. Int. Med.,
47:317-331, (Aug.) 1957.

2. Hamman, L., and Rich, A. R.: Acute diffuse interstitial
fibrosis of lungs. Bull. Johns Hopkins Hosp., 74:177-212,
(Mar.) 1944.

3. Fienberg, R.: Pathergic granulomatosis (Editorial). Am.
J. Med.. 19:829-831, (Dec.) 1955.

4. Rukavina, J. G., and others: Primary systemic amyloi-
dosis; review and experimental, genetic and clinical study of
29 cases with particular emphasis on familial form. Medicine,
35:239-334, (Sept.) 1956.

Annual Meeting of Iowa Thoracic
Society

James F. Speers, M.D., of Des Moines, president
of the Iowa Thoracic Society, invites all Iowa
physicians to attend the hospitality hour, dinner
and medical program of the organization’s annual
meeting, at Hotel Savery, Des Moines, on Wednes-
day, April 4.

The business meeting and election of officers
and executive committee members will be held
from 4 to 5:30 p.m. The hospitality hour will fol-
low the business meeting, and a dinner will be
served at 6:30. The medical program will begin
at 7:30.

William R. Barclay, M.D., an associate profes-
sor of medicine at the University of Chicago Col-
lege of Medicine, will discuss “Histoplasmosis.”
Harry E. Walkup, M.D., director of research for
the American Thoracic Society, New York City,
will present highlights of the United States Public
Health Service chemoprophylaxis study, which is
to be reported in full during April. Advance in-
formation on this study indicates that there will
be significant recommendations for TB control
programs involving physicians, health depart-
ments, and TB associations.

The chairman of the program committee is
George N. Bedell, M.D., of Iowa City. Others on
the committee are James E. Kelsey, M.D., and
Ralph A. Dorner, M.D., both of Des Moines.

Acceptances should be sent to the Iowa Thorac-
ic Society, 2124 Grand Avenue, Des Moines 12.
Wives are invited.

Coming Meetings

Mar. 15
Mar. 31

Apr. 6-8

Apr. 13-14

IOWA

Lederle Symposium. Sheraton-Martin Hotel,
Sioux City

Orthopedic and Rehabilitation Seminar. Youn-
ker Memorial Rehabilitation Center, Iowa
Methodist Hospital, Des Moines
Third Midwestern Sectional Meeting of the
Biological Photographic Association. Down-
towner Motor Inn, Des Moines
Pediatric Conference. Raymond Blank Me-
morial Hospital, Des Moines

Mar. 1-3

Mar. 2-3

Mar. 2-3
Mar. 2-4

Mar. 3
Mar. 3-4
Mar. 3-5
Mar. 5-7

Mar. 5-7
Mar. 5-9

Mar. 5-9
Mar. 6-7
Mar. 7-8

Mar. 7-9
Mar. 7-9
Mar. 8-10
Mar. 10

Mar. 12

Mar. 12-14
Mar. 12-15

Mar. 12-15

Mar. 12-16

Mar. 12-23
Mar. 13-15

Mar. 14
Mar. 14-18
Mar. 15-16
Mar. 15-17

CONTINENTAL U. S.

Conceptual Advances in Immunology and On-
cology, Sixteenth Annual Symposium on Fun-
damental Cancer Research. University of
Texas M. D. Anderson Hospital and Tumor
Institute, Houston

Operable Heart Disease, Fourth Annual Con-
ference. Presbyterian Medical Center, San
Francisco

Proctology. University of California, Los An-
geles

Annual Meeting of the American Society of
Psychosomatic Dentistry and Medicine. Shore-
ham Hotel, Washington, D. C.

Coronary Arteriosclerosis. Stanford University
School of Medicine, Palo Alto, California
Annual Meeting, New York Society of Inter-
nal Medicine. New York City
American Society of Facial Plastic Surgery.
New Orleans

Anesthesia for Specialists. Center for Con-
tinuation Study, University of Minnesota,
Minneapolis

Pediatrics Symposium. University of Kansas
School of Medicine, Kansas City, Kansas
Gastroenterology (American College of Physi-
cians). University of Michigan Medical School,
Ann Arbor

Surgery of Colon and Rectum. Cook County
Graduate School of Medicine, Chicago
Southwestern Pediatric Society Spring Lecture
Series. Statler Hotel, Los Angeles
Postgraduate Seminar on Diseases of Bone.
University of Missouri Medical Center, Co-
lumbia

Management of Trauma. University of Colo-
rado Medical Center, Denver
Pain Relief in Childbirth. Cook County Grad-
uate School of Medicine, Chicago
Ocular Motility. University of California, San
Francisco

Child Development (University of California,
San Francisco). Children’s Hospital, San Fran-
cisco

Spring Hospital Workshop Program (Kansas
City Southwest Clinical Society). Hospitals
of Greater Kansas City

Gallbladder Surgery. Cook County Graduate
School of Medicine, Chicago
Twenty-fifth Annual Meeting of the New
Orleans Graduate Medical Assembly. Roose-
velt Hotel, New Orleans

Canadian-American Medical Ski Association.
Iroquois Mountain, Mission Hill Lodge, Brim-
ley, Michigan

Selected Subjects in Internal Medicine (Amer-
ican College of Physicians). University of
Chicago Clinics, Chicago

Obstetrics, General and Surgical. Cook County
Graduate School of Medicine, Chicago
Loma Linda University School of Medicine
Alumni Postgraduate Convention. Ambassador
Hotel, Los Angeles

Lederle Symposium. Lee Jackson Hotel, Win-
chester, Virginia

Diagnostic Radiology. University of California,
San Francisco

Infectious Diseases. University of Nebraska
College of Medicine, Omaha

Clinical Symposium, Surgery of the Neck.
Cook County Graduate School of Medicine,
Chicago

Mar. 15-17
Mar. 15-17

Mar. 16-17

Mar. 17

Mar. 18-21
Mar. 18-22

Mar. 19-23

Mar. 19-30

Mar. 19-21

Mar. 20-22

Mar. 20-23

Mar. 21-24

Mar. 22-23

Mar. 24
Mar. 24-26
Mar. 26-28
Mar. 26-30
Mar. 26-30
Mar. 26-30
Mar. 26- Apr. 6
Mar. 26-Apr. 7

Mar. 27-28
Mar. 28-31

Mar. 29-31
Mar. 30-Apr. 1
Mar. 30-Apr. 1
Mar. 31-Apr. 1
Apr. 1-6

Apr. 2-4
Apr. 2-4
Apr. 2-4
Apr. 2-5
Apr. 2-6
Apr. 2-6

Surgery of Hernia. Cook County Graduate

School of Medicine, Chicago

Tenth Annual Cancer Seminar of the Arizona

Division of the American Cancer Society.

Westward Ho Hotel, Phoenix

Treatment of Traumatic Injuries. Center for

Continuation Study, University of Minnesota,

Minneapolis

Special Surgery of the Extremities. Presby-
terian Medical Center, San Francisco
Missouri State Medical Association. St. Louis
International Anesthesia Research Society.
The Americana, Bal Harbour, Florida
Advances in Surgery. Cook County Graduate
School of Medicine, Chicago

Basic Electrocardiography. Cook County Grad-
uate School of Medicine, Chicago
Obstetrics and Gynecology. Harvard Medical
School, Boston

Dallas Southern Clinical Society Spring Clin-
ical Conference. Statler Hotel, Dallas
Pre- and Postoperative Care. Medical College
of Georgia, Augusta

National Health Forum. Pick-Carter Hotel,
Cleveland

American Association of Anatomists. Minne-
apolis

Neurosurgical Society of America. Buena
Vista Hotel, Biloxi, Mississippi
Thirty-ninth Annual Meeting of the American
Orthopsychiatric Association. Biltmore Hotel,
Los Angeles

The Heart: Cardiac Arrhythmias Symposium.

University of Kansas School of Medicine,
Kansas City, Kansas

International College of Applied Nutrition
Annual Convention. Huntington-Sheraton
Hotel, Pasadena, California

Conference on Emergencies. Presbyterian
Medical Center, San Francisco
Skin and Internal Disorders. Stanford Uni-
versity School of Medicine, Palo Alto
Clinical Reviews. Mayo Clinic and Mayo
Foundation, Rochester, Minnesota
Proctoscopy and Sigmoidoscopy. Cook County
Graduate School of Medicine, Chicago
Treatment of Varicose Veins. Cook County
Graduate School of Medicine, Chicago
Vaginal Approach in Pelvic Surgery. Cook
County Graduate School of Medicine, Chicago
Basic Internal Medicine. Cook County Grad-
uate School of Medicine, Chicago
Techniques in Application of Cardiovascular
Disease. Scripps Clinic and Research Founda-
tion, La Jolla, California

Fractures in Children (University of Southern
California). Los Angeles Orthopaedic Hospital
American Dermatological Association, Inc.

(Members Only) San Marcos Hotel, Chandler,
Arizona

Cardiac Drugs. University of California, San
Francisco

Hypothermia. University of California, Los
Angeles

American Society for the Study of Sterility.
Drake Hotel, Chicago

American Psychosomatic Society. Sheraton
Hotel, Rochester, New York
American College of Allergists Graduate In-
structional Course and 18th Annual Congress.
Hotel Radisson, Minneapolis
American Radium Society. Waldorf-Astoria
Hotel, New York City

Clinical Reviews. Mayo Clinic and Mayo
Foundation, Rochester, Minnesota
Ophthalmology. University of Kansas School
of Medicine, Kansas City, Kansas
American College of Obstetricians and
Gynecologists. Palmer House, Chicago
Clinical Congress of Abdominal Surgeons.
Chicago

Thirty-fifth Annual Spring Congress in
Ophthalmology and Otolaryngology and Allied
Specialties (Gill Memorial Eye, Ear and
Throat Hospital). Patrick Henry Hotel, Ro-
anoke, Virginia

155

March, 1962

156

Journal of Iowa Medical Society

Apr. 4-6
Apr. 4-7

Apr. 5-7
Apr. 5-7

Apr. 5-7

Apr. 6-7
Apr. 6-8

Apr. 9-11

Apr. 9-12
Apr. 9-12

Apr. 9-13

Apr. 10-12
Apr. 12-14

Apr. 12-14
Apr. 13-14
Apr. 13-14
Apr. 13-14

Apr. 13-15
Apr. 15-18
Apr. 15-21
Apr. 16-18
Apr. 16-18

Apr. 16-20
Apr. 22-24
Apr. 23-25
Apr. 23-25

Apr. 23-28

Apr. 24-25

Apr. 25-28
Apr. 25-28

Apr. 26-28
Apr. 26-28

Apr. 26-28

Apr. 26-28
Apr. 28
Apr. 29

Otorhinolaryngology. University of Kansas
School of Medicine, Kansas City, Kansas

U.S.P.H.S. Clinical Society. Clinical Center,
National Institutes of Health, Bethesda, Mary-
land

Water, Salts and Steroids. University of
California, San Francisco

Current Concepts of the Physiology of the
Endocrines, Electrolytes and the Kidney.

(American College of Physicians in conjunc-
tion with the American Physiologic Society),
University of Pennsylvania, Philadelphia

Clinical Symposium: Surgery of the Newborn.

Cook County Graduate School of Medicine,
Chicago

Association of Clinical Scientists. Sheraton-
Chicago Hotel, Chicago

Annual Meeting of the American Society of
Internal Medicine. Benjamin Franklin Hotel,
Philadelphia

Anesthesiology. University of Kansas School
of Medicine, Kansas City, Kansas

Aerospace Medical Association. Atlantic City

Fourteenth Annual Scientific Assembly of the
American Academy of General Practice. Las
Vegas Convention Center, Las Vegas
Forty-Third Annual Session of the American
College of Physicians. Convention Hall and
Bellevue-Stratford Hotel, Philadelphia

Industrial Medical Association. Pick-Congress
Hotel, Chicago

Otolaryngology for General Physicians. Center
for Continuation Study, University of Min-
nesota, Minneapolis

Highlights of Modern Ophthalmology. Presby-
terian Medical Center, San Francisco

American Society for Artificial Internal Or-
gans. Hotel Claridge, Atlantic City, N. J.

Symposium on the Knee. Harvard Medical
School, Boston

Review of Advances in Surgery for G.P.’s.
Stanford University School of Medicine, Palo
Alto, California

American Association for Cancer Research.
Chalfonte-Haddon Hall, Atlantic City, N. J.

California Medical Association Annual Ses-
sion. Fairmont Hotel, San Francisco

American Society for Experimental Pathology.

Atlantic City, N. J.

American Association for Thoracic Surgery.
Chase-Park Plaza Hotel, St. Louis

Internal Medicine for Internists. Center for
Continuation Study, University of Minnesota,
Minneapolis

American Society of Biological Chemists, Inc.

Atlantic City, N. J.

Spring Session of the American Academy of
Pediatrics. Statler-Hilton Hotel, Los Angeles

Pan American Congress of Gastroenterology.
Hotel Roosevelt, New York City
Fifteenth Annual Spring Meeting, West Vir-
ginia Academy of Ophthalmology and Oto-
laryngology. Greenbrier Hotel, White Sulphur
Springs, West Virginia

American Academy of Neurology. Statler-Hil-
ton Hotel, New York City

American Society for Gastrointestinal Endos-
copy. Roosevelt Hotel, New York City

American College Health Association. Chicago

Sixth Postgraduate Course on Fractures and
Other Trauma (Chicago Committee on Trau-
ma of the American College of Surgeons).
John B. Murphy Memorial Auditorium, 50
East Erie Street, Chicago

General Surgery. University of California,
San Francisco

Surgery for Surgeons. Center for Continua-
tion Study, University of Minnesota, Min-
neapolis

Clinical Symposium: The Problems of Aging.
Cook County Graduate School of Medicine,
Chicago

American Gastroenterological Association. Ho-
tel Roosevelt, New York City
American Society for Clinical Nutrition. Chal-
fonte Hotel, Atlantic City, N. J.

American Federation for Clinical Research.
Haddon Hall, Atlantic City, N. J.

Apr. 29-30 American Otological Society, Inc. Sheraton
Dallas Hotel, Dallas

Apr. 29-May 2 International Academy of Pathology and
American Association of Pathologists and Bac-
teriologists. Queen Elizabeth Hotel, Montreal,
Canada

Apr. 30-May 1
Apr. 30-May 2
Apr. 30-May 2

Apr. 30-May 2
Apr. 30-May 3
Apr. 30-May 3

Society of Head and Neck Surgeons. Queen
Elizabeth Hotel, Montreal, Canada

Kansas Medical Society. Town House Hotel,
Kansas City, Kansas

Gynecology for General Physicians. Center
for Continuation Study, University of Min-
nesota, Minneapolis

American Academy of Pediatrics (Spring
Meeting). Statler-Hilton, New York City

Nebraska State Medical Association. Hotel
Cornhusker, Lincoln, Nebraska

American Proctologic Society. Deauville Hotel,
Miami Beach

ABROAD

Apr. 8-29

Apr. 15-18

May

May 3-6
May 13-19

May 14-18

May 21-July 9

May 26-30

June 16-21

July 30-
Aug. 13

Aug. 8-15

Sept. 5-8

Sept.

Oct. 7-13

Oct.

Clinical Postgraduate Program in Japan and
Hong Kong (U.C.L.A.). Contact: Thomas H.
Sternberg, M.D., Asst. Dean, Department of
Continuing Education in Medicine and Health
Sciences, U.C.L.A. Medical Center, Los An-
geles 24

Bahamas Medical Conference, Nassau. Con-
tact: Mr. Irwin N. Wechsler, Executive Direc-
tor, P. O. Box 1454, Nassau, Bahamas
World Health Organization, Palais de Nations,
Geneva, Switzerland. Write: Secretary-Gen-
eral, World Health Organization, Palais de
Nations, Geneva

106th Annual Meeting of the Hawaii Medical
Association, Honolulu.

World Congress of Gastroenterology, Munich,
Germany. Write: Medizinische Universitats-
klinik, Krankenhausstrasse 12, Erlangen, Ger-
many

International Congress on Hormonal Steroids,
Milan, Italy. Professor L. Martini, Instituto de
Farmacologia e Terapia, 21 Via A. del Sarto,
Milan

Medical Centers of Europe (University of
Southern California). Tuition: Part A. Lon-
don, Stockholm, Copenhagen and Paris (May
21-June 15) $250: Part B. Italy (June 16-30)
$150; Part C. Greece (June 30-July 9) $75.
For information write: Phil R. Manning,

M.D., Associate Dean, Postgraduate Division,
U.S.C. School of Medicine, 2025 Zonal Ave.,
Los Angeles 33

International Congress for Hygiene and Pre-
ventive Medicine. Vienna, Austria. Write:
Med. -Rat Dr. Ernst Musil, Mariahilferstrasse
177. Vienna 15

International Symposium on Enzymic Activity
in the Central Nervous System, Goteborg,
Sweden. Write: Dr. A. Lowenthal, Institut
Bunge, 59 rue Philippe Williot, Eerchem-
Antwerp, Belgium

International Fertility Association, 4th World

Congress, Hotel Copocabana, Rio de Janeiro.
Write: Dr. Maxwell Roland, Secretary, 109-23
71st Road, Forest Hills 75, New York
International Congress of Internal Medicine,
Munich, Germany. Write: Professor Dr. E.
Wollheim (President of Congress), Luitpold-
krankenhaus, Wurzburg, Germany
International Congress of Infectious Pathol-
ogy, Bucharest, Rumania. Write: Professor S.
Nicolau, Via Parigi, 7-Bucharest
Third International Conference on Alcohol
and Road Traffic, London. Write: Mr. J. D. J.
Havard, Secretary, Committee on Manage-
ment, British Medical Association House, Tavi-
stock Square, London

World Congress of Cardiology, Medical Cen-
ter, Mexico City. Write: Dr. I. Costero, In-
stituto N. De Cardiologia, Avenida Cuauhte-
moc 300, Mexico 7, D. F.

American Society of Plastic and Reconstruc-
tive Surgery, Hawaiian Village Hotel, Hono-
lulu. Write: T. Ray Broadhent, M.D., Sec-
retary, 508 East South Temple, Salt Lake City

Vol. LII, No. 3

Journal of Iowa Medical Society

157

National Poison Prevention Week

By act of Congress, the President of the United
States has been authorized to designate the third
week of March each year as National Poison Pre-
vention Week. In this year, the first of this na-
tional preventive program, the campaign will take
place from March 18 to 24. At a meeting of repre-
sentatives of groups vitally concerned with this
problem, it was decided to direct efforts this year
toward the prevention of accidental poisonings in
children under five years of age. In that age group,
some 302,000 children suffer accidental poisoning
each year.

The accidental poisoning of children is the re-
sult of thoughtlessness and carelessness, and not
infrequently it is the result of ignorance of the
toxic properties of many household remedies,
cleansing agents, insecticides, cosmetic prepara-
tions, etc.

Everyone concerned with the health and wel-
fare of children should give enthusiastic support
to the national campaign for poison prevention.
Information on accident and poison prevention
should be disseminated to every home in the land.
The family physician should play an active role,
making a conscientious effort to further this cause.
The prevention of accidental poisoning is fully as
important as the prevention of disease.

Have You Informed Us of Your
Change of Address?

Postal regulations on second class mail
have become more stringent. Under a new
ruling, we must pay ten cents per piece for
undeliverable second class mail, but worst of
all, if you don’t happen to reside or practice
at the precise mailing address which we have
for you, your journal will not be delivered.
We urge promptness on the part of all
journal readers in notifying us of address
changes!

The Diagnosing of Pulmonary Embolism

In 1959, Coon and Coller,1 of the University of
Michigan, reported that pulmonary emboli had
been found in 606 out of a total of 4,391 complete
autopsies — an incidence of 13.8 per cent. Pulmo-
nary infarction was found in 58.7 per cent of those
606 cases of pulmonary embolism. The rather
startling feature of that study was the fact that in
only 7.1 per cent of the patients with autopsy-
proved pulmonary emboli had a definite clinical
diagnosis been made prior to death.

In this group of patients, there had been no
signs or symptoms in 137 patients (27 per cent).
Shortness of breath was the most common symp-
tom, and was present in 291 cases. Shock occurred
in 138 patients. Chest pain was a symptom in 110,
and hemoptysis occurred in 54 patients. Physical
findings indicative of embolism were demonstrated
in 29 individuals (6 per cent). The authors con-
cluded that there are no specific diagnostic signs in
pulmonary embolism, and on the basis of this study
they decided that venous thrombosis is diagnosed
correctly even less often than is pulmonary embo-
lism.

In reviewing the clinical features of 72 patients
with pulmonary embolism, Barritt and Jordan,2
of the Bristol Royal Hospital, pointed out that
pulmonary embolism with infarction was one of
the commonest acute chest conditions met in hos-
pital practice, and that confirmation of the diag-
nosis was often difficult. The detection of pul-
monary emboli depended upon the correct inter-
pretation of symptoms, signs, electrocardiograms
and bedside roentgenograms. In contrast to the
report by Coon and Coller, in which infarction
was reported as having occurred in a little over
half of the cases, the British study indicated that
infarction was present in a considerable majority
of the patients.

The British authors were of the opinion that
the onset of pulmonary embolism was often ob-
vious from the temperature chart. A character-
istic patient, after a brief period of slight fever
suggesting venous thrombosis, became afebrile and
then, after a variable period, experienced a brisk
rise in pulse rate and then, after a few hours, a
rise in fever. That sequence of events was par-
ticularly significant in postoperative patients, who
were often afebrile for a day or two after surgery,
and had begun to recover when tachycardia and
fever reappeared. In this group of 72 patients, 18
experienced faintness; 12 had substernal pain; 58
had episodes of breathlessness without chest pain;
and 31 had hemoptysis. Hypotension occurred in 30
patients, and was attributed to a fall in left ven-
tricular output as a result of massive embolism.
Faintness, substernal pain and breathlessness sug-
gested pulmonary infarction.

The substernal pain resembled the pain of myo-
cardial ischemia, but the pain was less severe and
not so long-lasting. Pleural pain and hemoptysis,

158

Journal of Iowa Medical Society

March, 1962

which were considered to be symptoms of in-
farction, were accompanied by a fall in blood pres-
sure only when massive embolism had taken place.
Tachycardia was a common finding, arrhythmia
occurred frequently, and atrial fibrillation was
found in 13 patients. A rise in jugular venous pres-
sure was the most common sign of pulmonary
embolism, as shown by the distended neck veins.
Hypotension occurred in 20 patients. Auscultation
of the heart was of little help in diagnosis. Cya-
nosis and pallor occurred in massive embolism.

In cases with pulmonary infarction, the breath-
ing was rapid and shallow because of pleural
pain. Rales were present at the lung bases in all
but eight patients, and those eight all had massive
embolism with infarction. A pleural friction rub
was heard in 21 of 58 patients who had pleural
pain. Long dullness was elicited in 48 of the group.
Bronchial breathing was uncommon, for it was
heard in only two patients with massive embolism.

Examination of the legs in these patients re-
vealed nothing abnormal in 16 of them, but 32
had tenderness of the calf on squeezing, 10 had
superficial thrombophlebitis, 17 had varicose veins,
and 4 had fractured legs in plaster. The electro-
cardiogram was of value in about half of the
cases, particularly in those patients who had a
rise in venous pressure and a fall in systemic
blood pressure, together with other features that
suggested massive embolism. Bedside x-ray
showed positive findings in 45 patients, and was
normal in 16.

It was the feeling of the British authors that
an awareness of the disease, a careful history, the
alteration in the clinical chart, physical findings
consistent with thrombophlebitis or pulmonary
embolism, electrocardiography and occasional
roentgenograms of the chest represent the main-
stays of diagnosis. Yet at best these measures
often do no more than suggest the presence of
hidden disease.

Goreham,3 in a recent report, correlated the
clinical records, the nurses’ notes and the autopsy
findings in 100 cases of massive pulmonary embo-
lism among 5,700 autopsies at the New York Hos-
pital. According to that pathologist, no disease is
less frequently diagnosed than is embolism of the
pulmonary artery, whether involving major or
minor vessels. The major difficulty encountered
was the differentiation of massive pulmonary
embolism from myocardial infarction. Though
pathologists have recognized the findings at post-
mortem for many years, the clinicians have failed
to interpret correctly the symptoms produced by
the underlying anatomic and physiologic changes.
This situation is quite comparable to that of myo-
cardial infarction before the picture was elucidated
by Herrick in 1912. The electrocardiographic evi-
dence of cor pulmonale in pulmonary embolism

and the unusual clarity of the lung due to ischemia
in chest roentgenograms in massive pulmonary
embolism have helped to clarify the diagnosis. In-
sufficient attention has been given to the detection
and evaluation of physical signs in the recognition
of the condition.

According to Goreham, one of the commonest
mistakes has arisen from the synonymous use of
the terms infarct and embolism. “It is not often
realized,” he says, “that a large coiled embolus
occluding either the main stem or both branches,
or even occasionally a single major branch, does
not of itself necessarily produce an infarct of the
lung. As a rule, proper emphasis is not given to
the fact that the presence or the absence of a
pulmonary infarct depends on the size of the
embolus, its consistency, the size of the vessel
occluded, the presence or absence of pulmonary
congestion, and the degree of obstruction pro-
duced. ... In massive embolism, the lung paren-
chyma shows nothing abnormal, or at most moder-
ate atelectasis and edema in some cases.”

Confusion also results from the fact that in many
patients who are dying of massive pulmonary em-
bolism, small or even large areas of pulmonary
infarction develop. In Goreham’s series, 43 per
cent of the patients were found to have such areas
at postmortem. In contrast to massive embolism,
the signs and symptoms of pulmonary infarction
were less dramatic, and were produced by much
smaller emboli that occluded lobar or sublobar
branches of the pulmonary arteries. Not infre-
quently the lesion was silent, but in other patients
it was characterized by axillary pain on deep
breathing, bloody sputum, dullness, diminished
breath sounds or tubular breathing, rales, and if
an infarct extended to the pleura, a friction rub.
In massive pulmonary embolism, the onset was
sudden or apoplectic, with marked disturbance of
breathing as the initial symptom, accompanied by
pallor or cyanosis, shock, cardiac pain, a sharp
drop in blood pressure, and a weak, thready pulse.
Death usually occurred within five minutes to
two hours after the dramatic onset of symptoms.

Because the signs and symptoms of massive
pulmonary embolism and of myocardial infarction
are often very similar, making the differential
diagnosis extremely difficult, Goreham has pre-
sented 12 diagnostic clues, gathered from reports
of cases in the American and European literature.
One or more of those 12 have been described in
individual cases, and they may help physicians
to make the correct diagnosis of massive pulmo-
nary embolism. The distention of the pulmonary
artery gave rise to pulsation in the second left
interspace, a marked accentuation of the second
pulmonary sound, louder than the second aortic
sound, and a pericardial friction rub located
high in the left chest in the second or third in-
terspace. A systolic murmur in the second left

Vol. LII, No. 3

Journal of Iowa Medical Society

159

interspace, a diastolic murmur in the same area,
and an interscapular bruit have been attributed
to a partial stenosis of the pulmonary artery caused
by the embolus. The pulmonary hypertension has
been considered the cause of recognizable signs:
an increased cardiac dullness to the right of the
sternum; increased venous pressure with distended
neck veins; an enlarged liver; and a gallop rhythm
best heard over the second and third left inter-
spaces. A rare sign that has been described con-
sists of a momentary red wave which appears to
pass over the pallid, cyanotic face, and is thought
to be caused by the breaking off of a part of the
obstructing embolus, permitting an additional
amount of oxygenated blood to pass through the
lung to the left heart.

Walker and associates4 recently emphasized that
pulmonary embolism is the most common pul-
monary disease seen in a general hospital, and
that it is diagnosed accurately in no more than
20-50 per cent of cases, on the basis of the usual
clinical, radiographic and electrocardiographic
criteria. Pulmonary embolism is most frequently
confused, they say, with myocardial infarction
and with bronchopneumonia. This Boston group
report that serial determinations of a triad of lab-
oratory tests have contributed to the accuracy of
diagnosis. The serum lactic dehydrogenase (LDH)
was consistently elevated, the serum glutamic
oxaloacetic transaminase (SGOT) was consistent-
ly normal in a series of 17 cases of pulmonary em-
bolism with infarction, and the serum bilirubin was
consistently increased in 11 of 15 patients in whom
it was measured. The LDH usually reaches a max-
imum on the second day, and gradually falls to nor-
mal on the tenth day. The increase in bilirubin is
detectable in most instances as early as the fourth
day. In myocardial infarction, there is a simul-
taneous rise in both LDH and SGOT — a very help-
ful point in differentiating it from pulmonary em-
bolism. According to the authors, “The diagnostic
triad permits the diagnosis of pulmonary em-
bolization to be made promptly and with greater
accuracy than has been previously possible.”

Obviously, pulmonary embolism and infarction
are very common, and with the increase in the
numbers of people over 65 years of age, it is rea-
sonable that the incidence will grow. Diagnostic
accuracy in teaching hospitals varies from 20 to
50 per cent. The commonest diagnostic error is
confusion of pulmonary embolism and infarction
with myocardial infarction. Early, accurate diag-
nosis of pulmonary embolism and infarction are
important in order that immediate treatment may
be instituted and in order that further, possibly
lethal, emboli may be prevented. The accurate
diagnosis of massive pulmonary embolus is prob-
ably of no more than academic importance, for
the most part, but the clinician who prides himself
on his diagnostic acumen is considerably chagrined
when a pathologist proves him wrong.

REFERENCES

1. Coon, W. W., and Coller, F. A.: Clinicopathologic
correlation in thromboembolism. Surg., Gynec. & Obst.,
109:259-268, (Sept.) 1959.

2. Barritt, D. W., and Jordan, S. C.: Clinical features of
pulmonary embolism. Lancet, 1:729-732, (Apr. 8) 1961.

3. Goreham, L. W.: Study of pulmonary embolism: I.

Clinicalpathologic investigation of 100 cases of massive em-
bolism of pulmonary artery; diagnosis by physical signs and
differentiation from acute myocardial infarction. Arch. Int.
Med., 108:8-22, (July) 1961.

4. Wacker, W. E. C., Rosenthal, M., Snodgrass, P. J., and
Amador, E.: Triad for diagnosis of pulmonary embolism
and infarction. J.A.M.A., 178:8-13, (Oct. 7) 1961.

Penicillin Hazards

Penicillin has been in use for 20 years, and has
proved to be the most effective and least toxic
of the antibiotics. However, the drug has also
proved to be the most allergenic and most pro-
ductive of serious or even fatal hypersensitivity
reactions. A recent article by Harrison F. Flip-
pin,* professor of clinical microbiology at the
University of Pennsylvania, has discussed the ad-
verse reactions, the proper use and the precau-
tions that must be observed in the use of peni-
cillin, and his presentation is so effective that we
feel it should be made available to the physicians
of Iowa, as well as to those of his own state.

It has not been demonstrated that penicillin, a
non-protein drug, is in itself antigenic, but it is
thought that in vivo it combines with normal body
proteins to form a complex antigen that is capable
of antigen formation and sensitization. The wide
use of penicillin in nasal drops, sprays, creams and
ointments, and oral capsules, and administration
by the intramuscular route have sensitized a very
large share of the American people. The use of
penicillin by veterinarians in the treatment of
bovine mastitis has provided another route of
sensitization. The true incidence of penicillin
sensitivity is unknown, but there is no doubt that
it is increasing every year.

Fundamentally, there are four types of allergic
reactions to penicillin. The most important and
most serious of them is the anaphylactic or anaphy-
lactoid type, which produces circulatory collapse
a few seconds, or at most a few minutes, after in-
jection or ingestion. This dramatic and alarming
reaction produces death in approximately 10 per
cent of cases, or asthma and urticaria and angio-
neurotic edema develop.

A second type of reaction is the delayed one,
which appears from seven to 10 days after the ad-
ministration of the drug. It is manifested by fever,
malaise, urticaria, and joint and muscle pains.
Purpura, erythema multiforme or exfoliative der-
matitis may occur. Rarely, a serious and wide-
spread necrotizing arteritis or periarteritis nodosa
has resulted. A third type of delayed contact der-

* Flippin, H. F.: Penicillin ‘fallout.’ Pennsylvania m.j.,

6-4:1578-1581, (Dec.) 1961.

160

Journal of Iowa Medical Society

March, 1962

matitis is seen occasionally in individuals who
have been exposed to penicillin in ointments,
sprays or powders, or who have participated in the
manufacture of the drug. A fourth type consists
of a flare-up of a preexisting infection due to re-
lated fungi- — the so-called ID reaction.

Repeated or prolonged exposure to the drug pre-
disposes to hypersensitivity. Oral administration
is much less likely to induce hypersensitivity than
is injecton of the drug, for it is absorbed much
more slowly from the gastrointestinal tract. The
injection of penicillin in material designed to de-
lay absorption promotes the development of anti-
body and of allergic reactions. Patients with atopic
disease are much more likely to develop allergic
reactions and are made more seriously ill by them,
than are other people.

The detection of patients who will react to peni-
cillin is difficult. A personal or family history of
allergy, or previous administration of penicillin,
particularly in atopic individuals, should put the
physician on his guard. A previous reaction to
the drug probably indicates that the patient will
react again, and that the reaction will be more
severe. Unfortunately, a history will not reveal
sensitization from the administration of penicillin
in contaminated syringes, from vaccines contain-
ing minute amounts of the drug, or from the in-
gestion of milk and milk products containing the
antibiotic.

Dr. Flippin does not have much confidence in
the skin tests for sensitivity to penicillin, except
in patients who have had previous topical appli-
cations of the drug, in which case the drug will
react on contact. He cautions that the patch test
may result in a serious systemic reaction in a
hypersensitive patient. The testing of patients who
have had a previous reaction to penicillin is
dangerous and, as a general rule, should not be
done. Rather reluctantly, he agrees that proper
testing appears to be safer than a full therapeutic
dose of penicillin without testing, and that it may
reduce the occurrence of serious or fatal anaphy-
lactic reactions. It would appear, however, that
this recommendation is suggested for medicolegal
reasons, rather than from confidence in the merits
of the test.

Dr. Flippin clearly defines the measures that
should be employed to prevent penicillin hyper-
sensitivity:

1. Penicillin should be used only when indicated.

2. Extra care should be used in atopic individ-
uals.

3. Oral penicillin should be used, except in infec-
tions of the blood stream, endocardium, meninges,
etc. After oral penicillin, the patient should be
watched for a minimum of 30 minutes, since all
reactions to oral penicillin have occurred within
that length of time.

4. The administration of injectable penicillin
should, for the most part, be limited to the treat-

ment of hospitalized patients. There are very few
exceptions to this ride.

5. When penicillin is injected, it should be given
in the arm, and low enough so that a tourniquet
can be applied if necessary, and the patient should
be carefully observed for at least 20 minutes fol-
lowing the injection.

6. A patient who gives a history of any sort of
reaction to penicillin, even though it be question-
able, should not receive the drug. Another suit-
able agent should be substituted. The use of an-
other brand of the drug or of a so-called hypo-
allergic or synthetic preparation is hazardous.
Antihistamines given concurrently with penicillin
have proved ineffective, and may mask warning
signals of impending trouble.

7. If penicillin remains the only drug that can
be used in the treatment of a disease in a hyper-
sensitive patient, a calculated risk must be taken.
However, there are few diseases in which penicil-
lin is the only drug that can be used effectively. A
skin test must be done, even though it may have
no more than a medicolegal value. Ordinarily, in
such a case, oral administration is impracticable,
and the drug is given subcutaneously, in gradual-
ly increasing amounts, every 15 minutes, until a
therapeutic level has been reached. The patients
should first be protected by epinepherine and pos-
sibly by adrenocorticosteroids.

The treatment of the immediate anaphylactic re-
action consists of applying a tourniquet proximal
to the site of injection. Epinephrine should be
given intravenously until blood pressure levels
have been restored and are maintained. Though
antihistamines are ineffective in prophylaxis, they
are given to minimize the further release of hista-
mine. ACTH or adrenocorticosterones are recom-
mended to assure the effectiveness of the treat-
ment already given. Penicillinase is of question-
able value, and there is a possibility of anaphy-
laxis associated with its use. Delayed hypersensi-
tivity usually responds to treatment with anti-
histamines, but in the more severe and persistent
reactions, the adrenocorticosteroids are helpful.

Though penicillin is the most potent antimi-
crobial available for the treatment of many infec-
tions, the physician must constantly keep in mind
the hazard of a hypersensitivity reaction after
the administration of the drug. Like many other
drugs, penicillin cannot be used without some de-
gree of risk. It is the duty of every physician to
reduce that risk to a minimum by exercising prop-
er precautionary measures, and by giving the
drug only when necessary.

Help your central office to maintain an
accurate mailing list. Send your change of
address promptly to the Journal, 529-36th
Street, Des Moines 12, Iowa.

Vol. LII, No. 3

Journal of Iowa Medical Society

161

Prostatectomy Routes

It has happened rather frequently, in medicine,
that a new technic of therapy has almost com-
pletely supplanted a successful mode of treatment
that had been widely used for many years, and
then that the older method has gradually re-
turned to popularity. A recent article by Thomas
E. Gibson,* an assistant professor of urology at
the University of California School of Medicine,
suggests that a phenomenon of this sort is oc-
curring in surgery. Perhaps there is a swing back
to suprapubic prostatectomy as the method of
choice, after a long period in which transurethral
resection was in the ascendancy.

Dr. Gibson relates that, having been trained by
an enthusiast for perineal prostatectomy, he did
that type of operation exclusively for median bars,
vesical-neck contractures and obstructive pros-
tatic cancer not amenable to radical removal. Sub-
sequently, he learned to do suprapubic prostatec-
tomies and looked upon them with increasing
favor, since they were easier to do and posed less
hazard of urethral-sphincter and rectal injury.
After the introduction of the resectoscope, trans-
urethral prostatectomy became the popular meth-
od, and the author says he treated about 90 per
cent of bladder-neck obstructions in that manner.
As his experience with transurethral resection in-
creased, however, his enthusiasm for the technic
waned because of certain morbidity factors and
the necessity for reoperation after several years,
particularly in cases of adenomatous hyperplasia.

After years of experience with various methods
of treatment, Gibson now employs transurethral
resection in approximately 30 per cent of bladder-
neck obstructions. He uses it only in cases of ob-
struction from median bars, small hyperplasias,
vesical-neck contractures, certain neurogenic
bladder disturbances, and obstructing prostatic
cancer not amenable to radical removal. Supra-
pubic prostatectomy, he performs in about 60 per
cent of the cases, limiting the operation to benign
glandular hyperplasias which by their very nature
are easily enucleable. Perineal prostatectomy, he
does in about 10 per cent of the cases, where it is
indicated by the gross obesity of the patient, by
a suspicion of prostatic cancer, or by extensive
calculus disease of the gland. He is opposed to the
retropubic prostatectomy because it invades the
space of Retzius and creates a hazard of serious
infection.

As Gibson describes it, the modern technic of
suprapubic prostatectomy is a relatively brief
and uncomplicated operation. There is very little
bleeding, and packs and hemostatic bags are un-
necessary. Fewer than 10 per cent of patients re-
quire a unit of blood postoperatively. A large cali-

* Gibson, T. E.: Progress in prostatectomy, j. Louisiana
m. soc., 113:495-501, (Dec.) 1961.

ber suprapubic tube is removed after 24 hours.
A Foley 24F retention catheter with a 30 cc. bag
is left in place, and is usually removed on the
sixth or seventh day. The entire operation, he
says, should not require more than 15 to 30 min-
utes. Ordinarily, the wound heals per primnm,
and urinary leakage above seldom occurs. Not
only is the operation quick and easy to do, but
the patients are happy because the results are
uniformly good. The mortality for suprapubic
prostatectomy has been 1.62 per cent, in his ex-
perience, whereas for transurethral resection it
has been 1.88 per cent.

It would appear that transurethral resection
does not provide a complete solution to the prob-
lem of prostatic obstruction, and that the supra-
pubic operation is regaining favor for the correc-
tion of this condition.

Orthopedic and Rehabilitation
Seminar

younker Memorial Reha bilitation Center, Iowa Methodist
Hospital, Des Moines

Saturday, March 31, 1962

10:05 a.m. “Fractures of the Hip” — Carroll B. Larson,
M.D., head of the Department of Orthoped-
ic Surgery, S.U.I.

11:00 “Tenosynovitis of the Hand and Wrist” — -
Paul R. Lipscomb, M.D., consultant in or-
thopedic surgery at the Mayo Clinic, and
associate professor of surgery, University of
Minnesota

12:00 m. “Fractures of the Hand” — L. D. Howard,
Jr., M.D., Stanford University School of
Medicine

1:00 p.m. lunch

2:00 “Fractures of the Humerus” — Marcus J.

Stewart, M.D., associate professor of or-
thopedic surgery, University of Tennessee

3: 00 “The Use of Physical Medicine in Office
Practice: Post-fracture Therapeutic Meas-
ures”— G. Keith Stillwell, M.D., consultant
in physical medicine and rehabilitation,
Mayo Clinic, and assistant professor of
physical medicine and rehabilitation, Uni-
versity of Minnesota

4: 00 demonstration: prevention of deformity in

THE STROKE PATIENT

W. D. DeGravelles, Jr., M.D., and staff
members of the Younker Memorial Re-
habilitation Center

4: 30 TOUR OF YOUNKER MEMORIAL REHABILITATION

CENTER

A discussion period will follow each presentation.

162

Journal of Iowa Medical Society

March, 1962

President s Page

1 happened to be joking with an 89-year-old patient of
mine about the number and variety of accessories that he
must lay aside at night, and he responded by reciting these
verses that he had composed:

That old age is golden, I’ve often heard said,

But sometimes I wonder, when ready for bed,

With eyes on the table, my teeth in a cup,

A nd. ears on the dresser till time to get up.

Awaiting sweet slumber, I ask of myself,

“Are any more spares to be put on the shelf f”

My hair is so thin it will never stay put ;

My shoes are much smaller than swell of my foot;

My clothes wrinkle badly ; I slump in my seat;

My tongue wobbles madly, and so do my feet.

I fall from my bed, and I fall on the floor ;

With hip badly shattered, I holler for more.

But I really don’t, mind, for—

I’m forced to conclude, whatever my due,

Life still is worth living. At. age eighty-two
I toddle along, quite content, with my pills,

In zest of right living, forgetting life’s ills.

-C. W. Wakeman, 1955

The King -Anderson Bill Must Be Kept From Passage

The King-Anderson Bill, a proposal before the
current session of Congress, would make all re-
cipients of Social Security benefits eligible for
generous amounts of hospitalization and nursing-
home care, completely regardless of their ability
to pay for those attentions. Thus, it would help
many people who need no assistance and consti-
tute a prodigal waste of public money. It is the
latest attempt — and quite possibly the last — to
bring health care under the direct control of the
federal government. Many well-informed people
are convinced that if this measure fails of adop-
tion, the long battle in defense of the American
system of private health care will have been won.

In other words, 1962 is the crucial year. Now is
the time for greatest effort by everyone who
cherishes private enterprise and individual liber-
ties. Each of us must make sure that his congress-
man and senators are aware of his wishes.

SCHEMES TO BRING A VOTE ON KING-ANDERSON

The proponents of the King-Anderson Bill are,
for the most part, the same people who sought the
passage of the Wagner-Murray-Dingell Bill ten or
more years ago, and of the Forand Bill two years
ago. The King-Anderson scheme proposes only
hospital and nursing-home care under Social Se-
curity because its sponsors want it to seem that
physicians would be unaffected by such a measure
and thus can have no reason for opposing it. But
its adoption would be an opening wedge.

The King-Anderson Bill has been referred to the
House Ways and Means Committee, and in its
present form it seems likely to go no farther along
the ordinary road toward passage, since the chair-
man, Representative Wilbur Mills (D., Ark.) and
about half of the other members of the Committee
oppose it. But several devices for by-passing the
House Ways and Means Committee are being con-
sidered. Pressures of various sorts are being put
upon Mr. Mills to get him to let his Committee
discharge the Bill; there is a chance that sufficient
numbers of representatives can be persuaded to
sign a petition for the House to vote on the meas-
ure without the Committee’s approval; or an

amendment embodying the major provisions of
the Bill may be attached in the Senate to any of
several measures that the House will have passed,
in which case it is supposed that the House might
be virtually compelled to concur.

At the moment, the last of these alternatives
seems most likely to be tried, but its chances of
success aren’t too bright. The Constitution gives
the House of Representatives the exclusive right to
originate all appropriations measures, and though
the procedure just outlined might technically be
constitutional, it would be sure to meet the opposi-
tion not only from representatives who oppose the
inclusion of health care under Social Security but
also from many of them who are intent upon pre-
serving an important prerogative of the House.

KERR-MILLS PROGRAMS ARE SUCCEEDING

Mr. Mills and the rest of us who oppose provid-
ing health care to all Social Security beneficiaries
believe that government assistance to elderly
people in meeting the cost of illness can most fairly
and equitably be given through the Kerr-Mills Act,
a measure that Congress passed during the fall of
1960. Under it, federal funds are provided to the
states in matching grants for the support of what-
ever programs the states choose to set up for the
needy and near-needy aged.

As of December, 1961, 28 states and three U. S.
possessions had passed Medical Assistance for the
Aged legislation, and three other states, whose
legislatures still remained in session, were consid-
ering the enactment of such laws. Twenty-one pro-
grams were already in operation. Some other
states had improved their programs for medical
aid to the strictly indigent, and thus a total of 42
states and possessions had taken steps, by that
time, to avail themselves of the assistance offered
under the Kerr-Mills Act.

Iowa is one of a small number of states where
Kerr-Mills enabling acts were passed but no state
funds were appropriated to help the near-needy
pay their health-care costs. The legislatures of
those states acted in good faith, intending to put

such programs into operation within a year or two.
But a few legislatures refused to act, hoping that
the adoption of the King-Anderson Bill or another
similar measure at the national level would take
the responsibility off their hands, and a few legis-
latures passed Kerr-Mills enabling acts but simul-
taneously memorialized Congress of their desire
for health care to the aged under Social Security.

West Virginia was one of the group of states last
referred to, and presumably in an attempt to sup-
port the legislature’s point of view, the West Vir-
ginia commissioner of public welfare seems to
have attempted wrecking his Kerr-Mills program.
Newsweek reported a few weeks ago that after 14
months of operation, the West Virginia program
had paid claims totaling $3,674,363, had unpaid
bills of $1,500,00, and had incurred administrative
expenses of $350,000. The report said that the com-
missioner, a Mr. Smith, had announced that he
was cutting the number of elig'ibles in half, was
reducing pay for doctors’ visits from $3 to $2 each,
was cutting hospital payments from $35 to $20 per
day, and was limiting prescription costs to the
wholesale price plus $1 each for a handling charge.

Mr. Smith also had attempted to put the doctors
and hospitals in a bad light by reporting that all
but 132 of the 1,800 physicians, and all but 23 of
the 108 hospitals in that state “quit the program”
when he announced his cuts in compensation.

The facts however, are these:

1. The eligibility standards with which West
Virginia started its program of Medical Aid to the
Aged had been ridiculously liberal, and the wel-
fare workers had campaigned to get people to
qualify for the benefits.

2. The original fee of $3 per visit for doctors’
calls had been only 75 per cent of the Blue Shield
allowance, and the cut to $2 was just one of the
reductions that doctors were asked to accept. No
more than $40 was to be paid for any type of
surgery.

3. The average hospitalization cost for which the
West Virginia welfare department had been pay-
ing was $20.58 per patient-day, rather than the
$35 per day that had been mentioned in Newsweek.

4. The per-patient cost of the program had not
snowballed during the 14 months that preceded
the issuance of Mr. Smith’s ultimatum. In January,
1961, the figure was $77, and in June, 1961, for
example, it had fallen to $64.

5. Until his well-publicized decision in Decem-
ber, Mr. Smith had made no attempt to limit eligi-
bility, though the West Virginia legislature had
given him considerable latitude in setting the
qualifications, ruling only that recipients might
have annual incomes of no more than $1,500 per
couple.

6. No hospital or doctor actually quit the West
Virginia program. When Mr. Smith made his an-
nouncement, he asked hospitals and doctors to re-
enlist, accepting the reduced fees. Understandably,
few of them made haste to accept his invitation,
but they continued providing care to everyone,
just as they used to do, in return for whatever the

patients could reasonably pay. Belatedly, the
West Virginia state welfare department negotiated
with the hospital and physician groups, agree-
ments were reached, net-worth requirements for
eligibility were stiffened realistically, and the pro-
gram stayed solvent through the remaining few
weeks of 1961. Now the legislature has voted ade-
quate funds for its continuance.

The foregoing statements should demonstrate
that Kerr-Mills implementations can succeed, de-
spite the efforts of unfriendly administrators and
in states worst affected by chronic recession.

BROADENING OF PRIVATE INSURANCE PROGRAMS

For elderly people who are marginally capable
of financing their own health care, Iowa Blue
Shield and Blue Cross began offering their “Sen-
ior-65” plan nearly three years ago. Under it, 6,000
elderly Iowans having incomes no greater than
$2,000 per year and net worths no greater than
$20,000 are guaranteed 30 days’ hospitalization per
admission and whatever they need in the way of
surgery and inpatient medical care for a premium
of $6.35 per month.* To make that plan possible,
Iowa physicians have been accepting 60 per cent
of their standard fees as full payment for their
services.

On January 18, 1962, National Blue Shield an-
nounced a similar arrangement to provide surgery
and inpatient medical care for marginally self-
sufficient old people all over the country. They are
eligible provided that their incomes are no larger
than $2,500 for a single person or $4,000 for a
couple. Since Iowa Blue Shield already offers an
equally good plan, the national arrangement may
be offered only in other parts of the country. At
about the same time, National Blue Cross an-
nounced its national plan, but suggested — mis-
takenly, most physicians think — that the federal
government could undertake to subsidize it by
whatever means it might choose. In consequence,
perhaps, of guaranteeing too long a period of hos-
pitalization per admission, and in the expectation
that Uncle Sam would help pay the bills, National
Blue Cross seems to have made its offer to elderly
people disproportionately expensive. There re-
mains a good possibility, however, that the two
organizations can reach an agreement on a joint
nationwide arrangement resembling that which
their respective subsidiaries in Iowa are already
offering.

SUMMARY

The King-Anderson proposal, like its prede-
cessors the Wagner-Murray-Dingell Bill and the
Forand Bill, not only would add to the total cost
of health care, but would jeopardize essential lib-
erties of all Americans quite needlessly. Instead,
each of us must do his best to see to it that the
Kerr-Mills Act and the non-governmental health-
insurance plans are utilized fully in providing for
the health needs of the elderly.

* No more than $3,000 income and $30,000 net worth are
the requirements for a married couple.

BOOKS RECEIVED

TEXTBOOK OF ENDOCRINOLOGY, THIRD EDITION, by
Robert H. Williams, M.D. (Philadelphia, W. B, Saunders
Company, 1962. $21.00).

ATLAS OF CLINICAL ENDOCRINOLOGY, SECOND EDI-
TION, by H. Lisser, M.D., and Roberto F. Escamilla, M.D.
(St. Louis, The C. V. Mosby Co., 1962. $23.00).

THALASSEMIA: A SURVEY OF SOME ASPECTS, by Robin
M. Bannerman, M.A., D.M., M.R.C.P. (New York, Grune
& Stratton, Inc., 1962. $6.50).

POSTPARTUM PSYCHIATRIC PROBLEMS, by James Alex-
ander Hamilton, M.D. (St. Louis, The C. V. Mosby Co.,
1962. $6.85).

THE SCIENCE OF DREAMS, AN ANALYSIS OF WHAT
YOU DREAM AND WHY, by Edwin Diamond. (New York,
Doubleday & Co., Inc., 1962. $4.50).

CARCINOMA OF THE CERVIX, by John B. Graham, M.D.,
Luciano S. J. Sotto, M.D., and Frank P. Paloucek, M.D.
(Philadelphia, W. B. Saunders Company, 1962. $14.00).

COMMON SENSE ABOUT PSYCHOANALYSIS, by Rudolph
Wittenberg. (New York, Doubleday & Co., Inc., 1962. $3.95).

IRRITATION AND COUNTER-IRRITATION, by Adolphe D.
Jonas, M.D. (New York, Vantage Press, Inc., 1982. $7.50).

BOOK REVIEWS

The Physiology and Pathology of Leukocytes, ed. by
Herbert Braunsteiner , M.D. (American edition pre-
pared and revised by Dorothea Zucker -Franklin,
M.D.). (New York, Grune & Stratton, Inc., 1962.
$15.00).

Numerous contributors have brought together a
large body of fragmentary information relative to the
normal and abnormal physiology of leukocytes. In this
American edition, some phases of the subjects have
been omitted because American texts have already
treated them adequately. The chapters to which I
refer are those concerning the reticulo-endothelial
system and regulation of cells in the peripheral blood.

This book is definitely for the person who wishes
to “go the second mile” on the subject of leukocyte
function. It records factual data as well as theory in
a poorly understood field.

In addition to data on the usual circulating leuko-
cytes, there are discussions of plasma cells and mast
cells, since they are regarded as having close rela-
tionships with leukocytes.

Of interest to certain parties are chapters on radia-
tion injury, leukocyte antibodies including the L.E.
phenomenon, nuclear sex patterns, transplantation of
hematopoietic cells, hereditary anomalies of granulo-
cytes, the life span of leukocytes, and the leukemia-
virus problem.

The book will be of value to teaching-hospital li-
braries and to those physicians who have a special
interest in hematology. — David Baridon, Jr., M.D.

Psychiatry — Biological and Social, by Ian Gregory,

M.D. (Philadelphia, W. B. Saunders Company, 1961.

$10.00).

This carefully prepared work is a textbook of psy-
chiatry that should appeal especially to those inter-
ested in the methodology of psychiatric research.

The author adheres faithfully to his stated aim — to
present his material in a scientific, well-organized
manner, avoiding esoteric language, defining his terms,
and attempting to distinguish clearly between specu-
lation and reasonable probability.

He obviously is very well informed in genetics, and
deals rather extensively with the genetic factors in
psychiatry. But in spite of his interest in that field, he
keeps its etiologic role in proper perspective, and at-
tempts to integrate it with other causal agents — psy-
chological, sociological and cultural. His treatment of
the application of eugenic principles in the preven-
tion of psychiatric disorders is penetrating and scholar-
ly, as is his entire chapter “Causation and Primary
Prevention.”

The first chapter of the book should be of special
interest to the non-psychiatrist physician. It contains
an excellent, concise and unbiased presentation of the
various theoretical orientations in psychiatry, and of
the ways in which those orientations affect the prac-
tices of psychiatrists espousing various ones of them.

This book is intended to be holistic and eclectic, but
it is doubtful that it achieves a truly holistic syn-
thesis because of its emphasis on the measurable data
arrived at by strictly scientific and statistical means,
as distinguished from observations and hypotheses
based on clinical experience and integrated with
physiological and philosophical considerations. In the
biological field, genetic considerations receive much
closer attention than the biochemical or neurophysio-
logical. In the social area there is a preponderance of
measurables. For example, the incidence and distri-
bution of clinical entities in various socio-economic
levels of society receive more emphasis than do the
more intangible factors such as the intricacies of the
individual’s interpersonal relations and the intra-
psychic conflicts that they engender. On the whole,
this textbook deals more with generalizations than
with the individual psychiatric patient and his losing
struggle to adjust. This is exemplified by the paucity
of case material.

The book will find a more receptive audience
among the research-minded, especially those inter-
ested in research methodology as applied to the field
of psychiatry, than among clinicians looking for hints
as to how they can best help their patients with emo-
tional, behavioral or mental aberrations. — Thomas P.
Board, M.D.

163

164

Journal of Iowa Medical Society

March, 1962

Introduction to Anesthesia: The Principles of Safe
Practice, by Robert D. Dripps, M.D., James E. Eek-
enhoff, M.D., and Leroy D. Vandam, M.D. (Phila-
delphia, W. B. Saunders Company, 1961. $8.00).

As its name implies, this book is an introduction to
anesthesia, and the fundamental principles and prac-
tices are dealt with in detail. I feel that the book is
well written and easy to read. Such phases of anes-
thesia as pre-anesthetic medication, fundamentals of
inhalation, local and spinal anesthesia, the technic of
intubation, and muscle relaxants are discussed in de-
tail, as are some of the complications of anesthesia
such as hypotension, lung injuries, injuries to the
nerves, et cetera. Some space has also been devoted
to some of the more recent adjuncts of anesthesia such
as hypothermia, external cardiac resuscitation, man-
agement of coma, oxygen therapy and mechanical
ventilators.

I feel that this book is of interest to all anesthesi-
ologists, but more specifically to students of anesthesi-
ology.— Harold L. Klocksiem, M.D.

Eye Symptoms in Brain Tumors, by Alfred Huber ,

M.D. (St. Louis, The C. V. Mosby Company, 1961.

$16.00).

This scholarly presentation is enhanced by the
depth of the author’s knowledge of neurology and
ophthalmology. He presents the subject in detail, and
shows the correlation of anatomy, physiology and
pathology with the clinical history and findings.

The volume is replete with excellent illustrations,
and contains an almost encyclopedic bibliography. It
will enhance the armamentarium of every ophthal-
mologist, neurologist and neurosurgeon, and the
library of each such physician would be woefully in-
adequate without it. — Walter D. Abbott, M.D.

Blank Hospital Pediatric Conference

The Sixth Annual Pediatric Conference, spon-
sored by the Raymond Blank Hospital Associa-
tion, the Division of Maternal and Child Health of
the Iowa State Department of Health, the Iowa
Pediatric Society and the Raymond Blank Hos-
pital Guild, will be held at the Younker Memorial
Rehabilitation Center, Iowa Methodist Hospital,
Des Moines, on April 13 and 14.

The program is to include a full day of presenta-
tions on Friday, followed by a banquet at the Des
Moines Club, and a clinical conference and lec-
tures that will occupy the whole of Saturday. The
guest speakers will include Robert A. Aldrich,
M.D., of the University of Washington, Seattle;
John D. Crawford, M.D., of Harvard; Robert B.
Lawson, M.D., of Northwestern University; Irv-
ing Schulman, M.D., of the University of Illinois;
and Genevieve Stearns, Ph.D., of S.U.I.

Advance registrations are requested, and since
the national bowling tournament will be crowd-
ing the Des Moines hotels and motels, those who
wish housing should avail themselves of the Pro-
gram Committee’s offer to make those arrange-

ments no later than April 5. Registration is $20 for
both days, or $10 for just one. The registrant’s
luncheon ticket (s) will be included in his registra-
tion fee, but ones for physicians’ wives are $1.50
each. Banquet tickets are $6 each. Address: Char-
lotte Fisk, M.D., 3200 University Avenue, Des
Moines 11.

Summer Camp for Diabetic Children

The Summer Camp for Diabetic Children will
be conducted for the fourteenth successive year,
from July 15 through August 5, 1962, at Holiday
Home, Lake Geneva, Wisconsin, under the aus-
pices of the Chicago Diabetes Association. Boys
and girls from eight through 14 years of age are
eligible.

As in previous years, the camp will be staffed
by resident physicians, a nurse, two dietitians
and a laboratory technician, in addition to the
regular counseling and domestic staff of Holiday
Home.

Rates are arranged to suit individual circum-
stances.

Application blanks can be obtained from, and
inquiries should be directed to: Chicago Diabetes
Association, 620 North Michigan Avenue, Chicago
11. The first review of applications will take place
on March 20.

The Socialized State

O. G. POWELL, Des Moines
President, National Association of Real Estate Boards

If there is any significant peril in the future
course of this country, it is to be found in the
shackles and chains of political controls; it is to
be found in the corruption of political freedom
and the burgeoning of the socialized state.

I have no substantial concern over the ebb and
flow of the economic tides. I know that in a free
economy there must be times of plenty and times
of want, periods of prosperity and periods of
privation. In 1932 we saw business go down into
the economic valley of the shadow of death, only
to come out again with new and greater vigor.
And I have seen it falter in some measures of dis-
tress a half dozen times in the four decades of my
commercial life. But, may I say in passing, I never
saw any economic trouble not cured by salesman-
ship, ingenuity, imagination, inspiration — the fuel
which powers the whole economic machine.

I would not deny to a younger generation the
privilege of making its own mistakes.

Yet, I ask myself, do I have the right to fasten
on to the charging chariot of another generation
the burden of a 300 or 400 billion dollar national
debt?

Do I have the right to enfold the political econ-
omy of that generation in a straight jacket of con-
trols, restraints and regulations?

Vol. LII, No. 3

Journal of Iowa Medical Society

165

Do I have the right to shadow their lives with
the clouds of fear and the fog of futility?

Do I have the right to lay at their doorstep the
trials and travails of all the world from the
jungles of Africa to the ice lands of Mongolia?

Let us look, not as sociologists or research sci-
entists or political economists or statisticans — they
can be wrong, too — let us look as plain people at
the intangibles that affect the environment and
the future of this country — very real intangibles
which are grown out of the expanding trend
toward socialization of the political state, on the
one hand, and the quest for personal power, on
the other.

Partly by indifference, partly by neglect, partly
by self-indulgence, we have let the shrewd and
devious and alert protagonists of the socialist
state creep up upon us and almost surround us.
Let us recognize that a socialized state is a social-
ized state, whether you call it by the name of
communism or socialism, or disguise it in catch
phrases designed to have popular appeal.

No place is the issue between the free play of
private enterprise and state control more clearly
joined than it is in the area of public housing.
Here we have a gargantuan economic Franken-
stein created by the people themselves, feeding
upon tax exemption, tax subsidy and tax avoid-
ance, acting to destroy communities . . . regiment
society, perpetuate poverty and thwart enterprise.

This social misfit has been foisted upon the
public in a variety of guises, originally, as a proj-
ect in “make work,” later as a project to relieve
a war-induced housing shortage, later as a project
to rebuild slums, and now — frankly — as a project
in social regimentation.

The public-housing proponents know no limits.
They would reach into the smallest hamlet as well
as into the largest city, and into every class of
the residential economy and into every economic
stratum. Until we have restricted and restrained
this wanton abuse of every principle of American
tradition, we will have failed in our duty to
posterity — our duty to society.

Not too far from the institution of public hous-
ing is the program of “urban redevelopment,”
which appears in far too many cases to be more
closely associated with urban destruction. Under
its banner, we have carried forward a program
of spot reclamation using the bulldozer and the
wrecker’s ball — destroying satisfactory housing, in
many cases, and frequently destroying established
patterns of community life, to the distress of the
people who have made their homes in the affected
areas.

Too often, the effect of these projects has been
to relocate slums, rather than to eradicate them,
and in our big cities new areas of deterioration
have followed just as fast as the old areas have
been removed, if not faster.

Surely it is time now for another long look at
this business of urban rebuilding under the guid-

ance and the dictates of a federal bureaucracy.
It is time to put the burden of cost as well as the
responsibility of control back upon the commu-
nities.

The burden of real estate tax is, of course, one
that we shall always have with us, and it is a
burden which is to be accepted by the property
owner as a price to be paid for orderly govern-
ment. But such acceptance does not imply that
burden shall be permitted to become so onerous
as to destroy both the incentive and the ability
to own property.

Too often, extravagance, waste, luxury and graft
have been added to the cost of municipal services.

Too often the administration of welfare is viewed
in terms of political expediency, rather than in
terms of the relief of justifiable needs.

Too often has the cost of education been ex-
panded to include frills and foibles, rather than
the fundamentals of learning.

Too often have we lost sight of the necessity for
balance between the need for social services and
our ability to provide them.

Perhaps if I were discreet rather than candid,
I wouldn’t talk very much about the mounting
menace of the thing we call “forced housing.”
And yet I would tell you that all around the na-
tion a vicious and unrelenting campaign is be-
ing carried on to provide by legislation and by
executive decree a rule that a man cannot sell
or rent his house to a person or persons of his
own choice.

Here is perversion of the traditional constitu-
tional rights of the American citizen in its most
vicious form.

Here are the seeds of the breakdown of a free
America. Take away rights of property ownership,
and human rights become a relic of another age.
Here is our greatest challenge.

Let us give unto Caesar all the things which are
properly his, and keep for free men the legacy of
their birthright. Let us get the federal govern-
ment out of the housing business, out of the
mortgage business, out of the school business.

Let us quit perverting the FHA into fields of
social welfare and old age benefits. Let FHA do
the job it did so well for so many years — just sim-
ply the insurance of mortgage credit.

If America faults, if America denies to its sons
their freedom and independence, these are and
will be our faults. Let us, Americans, do some-
thing about it.

Annual Cancer Seminar in Phoenix

The Arizona Division of the American Cancer
Society will hold its Tenth Annual Cancer Sem-
inar at the Westward Ho Hotel, in Phoenix, on
March 15, 16 and 17. The topics to be discussed
are carcinoma of the breast, tumors of children,
skin tumors, cancer research, and perfusion. The

166

Journal of Iowa Medical Society

March, 1962

principal speakers include H. O. Sjogren, M.D., of
the Karolinska Institute, Stockholm; Sir Macfar-
lane Burnet, of the Institute of Medical Research,
Melbourne; Michael Feldman, M.D., of the Weiz-
man Institute of Science, Rehovoth, Israel; J. R.
Marrack, M.D., of Cambridge University; and Fer-
nando G. Bloedorn, M.D., head of the Division of
Radiotherapy at the University of Maryland.

Copies of the complete program and additional
information can be secured from W. Albert Brew-
er, M.D., 543 East McDowell Road, Phoenix.

Stress Response to Reserpine

Reserpine, a widely used tranquilizer and anti-
hypertensive drug, can interact with the body’s
nervous and hoi’monal mechanisms to produce a
biochemical picture almost indistinguishable from
the classical “stress” response evoked by pro-
longed exposure to cold, pain, and similar un-
pleasant stimuli, studies by Public Health Service
scientists indicate.

These findings are reported in the current issue

of the JOURNAL OF PHARMACOLOGY AND EXPERIMEN-
TAL therapeutics by Drs. Roger P. Maickel, Erik
O. Westermann, and Bernard B. Brodie, of the
National Heart Institute.*

The work cited is part of a program of research
being conducted by the NHI Laboratory of Chemi-
cal Pharmacology under the direction of Dr.
Brodie. The aim of this program is a fuller under-
standing of the biochemical basis of behavior, par-
ticularly of those biochemical mechanisms that
enable the organism to adapt to environmental
changes.

The studies showed that reserpine, when given
to rats, causes excessive secretion of the pituitary
hormone ACTH, the release from the adrenal
glands of large quantities of corticosterone, and
the mobilization of free fatty acids from the body
fat depots. These responses to reserpine are strik-
ingly similar to those evoked by prolonged ex-
posure to cold, pain, and similar “stresses.”

Even more paradoxical were the subsequent
findings that the stress responses were set off only
by doses of reserpine large enough to produce
sedation, and apparently resulted from the same
action of reserpine responsible for its tranquilizing
effects. Further, the stress responses to reserpine
could be prevented by monoamine oxidase inhibi-
tors, a class of drugs usually employed as anti-
depressants rather than as “anti-stress” drugs.

The sedative and tranquilizing effects produced
by reserpine result from its action on two brain
amines: norepinephrine and serotonin. The drug
blocks the ability of the brain to store these
amines. As a result, large quantities of these

* The National Heart Institute, located at Bethesda, Mary-
land, is one of the seven National Institutes of Health of the
Public Health Service. Department of Health, Education, and
Welfare.

amines are liberated to diffuse passively away or
to be set upon and destroyed by enzymes. This
steady drain eventually depletes the brain of most
of its norepinephrine and serotonin.

A preponderance of free norepinephrine in the
brain is usually associated with arousal and with
active behavioral patterns, a preponderance of
free serotonin with sedation, tranquility, and re-
cuperative behavior patterns. Reserpine attacks
the storage sites of both amines indiscriminately.
However, as the brain levels of both decline, free
serotonin predominates over free norepinephrine.
This occurs because serotonin is made at a faster
rate by the brain than is norepinephrine. The
result; tranquility and sedation — up to a point.

The NHI studies showed that, when brain amine
levels dropped to about 50 per cent of normal in
reserpine-treated animals, the pituitary and adre-
nal glands abruptly entered the picture. The pitui-
tary began to release large quantities of ACTH,
which, in turn, triggered the release of corticoster-
one and other steroid hormones from the adrenal
cortex. These hormones, acting in concert with
catechol amines from the adrenal medulla or re-
leased locally in adipose tissue, led to the mobili-
zation of free fatty acids. In short, these animals —
outwardly tranquilized, even stupefied — were ex-
hibiting most of the classic biochemical responses
to stress.

Subsequent studies on this state of “stressful
tranquility” showed that the pituitary-adrenal re-
sponses did not result from a direct action of
reserpine. They were related, however, to the
drug’s depletion of brain amines, specifically sero-
tonin. Whenever brain serotonin levels fell below
50 per cent of normal, the stress responses were
elicited. They were not elicited by drugs which
selectively depleted brain norepinephrine but not
brain serotonin.

Monoamine oxidase inhibitors, widely used as
antidepressant drugs, could block the pituitary-
adrenal responses to reserpine. They did so by
blocking the enzymatic destruction of the free
amines released by reserpine. This action slowed
the decline of brain amines and usually prevented
them from falling as far as the magic 50 per cent
level.

The pituitary-adrenal response to reserpine
would also disappear eventually even if further
reserpine were administered. The pituitary, it
appears, could not stand the strain forever, and
eventually ran out of ACTH to secrete.

Reserpine, grain alcohol, and a number of other
so-called depressant drugs have been found to
trigger the excessive secretion of ACTH by the
pituitary that sets these “stress responses” in
motion. How they do it is not yet known, but the
NHI scientists are trying to find out. Basic knowl-
edge about the interaction of drugs with the body’s
nerve and hormonal mechanisms is becoming in-
creasingly essential to the proper therapeutic
evaluation of new drugs.

Las Vegas AAGP Assembly

A gourmet’s medical smorgasbord, featuring
such familiar entrees as backache and appendicitis
as well as philosophical delicacies like “death with
dignity” and “undetected murder,” will be served
family doctors attending the Fourteenth Annual
Scientific Assembly of the American Academy of
General Practice April 9-12 in Las Vegas, Nevada.

Upwards of 3,000 Academy physicians are ex-
pected to visit Las Vegas to whet their professional
appetites on this bill of fare designed both to pre-
view new horizons in practical therapeutics and
to re-emphasize the more important aspects of
basic medicine. The 1962 Assembly will be the first
national medical conclave to be held in the new
7% acre Las Vegas Convention Center.

Of the more than 100 national medical associa-
tions, the Academy is the only one that requires
its members to do continuing postgraduate study.
Each member must complete 150 hours of accred-
ited postgraduate study every three years. For
this reason, the Assembly plays a vital role in the
Academy’s study program.

The scientific program will open Monday after-
noon (April 9), on the heels of the 2-day annual
meeting of the Academy’s policy-making Congress
of Delegates, which will have started the preceding
Saturday at the Flamingo Hotel. The initial offer-
ing of the 25-lecture program will be a symposium
and panel discussion on the growing field of geri-
atric medicine and the leading role general practi-
tioners must assume in the health problems of an
aging population.

Tuesday’s program will range from a penetrating
reappraisal of cesarean section to discussions of
the latest work in practical orthopedics. On the
afternoon program are surgical considerations of
appendicitis in the antibiotic era, and of facial
injuries requiring plastic reconstruction.

The spotlight swings Wednesday to pediatrics,
vascular disorders, diabetes and thyroid difficul-
ties, and also provides some peeks into medicine’s
future. Highlighting the morning session will be
a recapitulation of the grim factors involved in
unexpected death in infants, a timely briefing on
the still-experimental measles vaccine by one of
its developers, and an “avant-garde” discussion on
electronics in medicine. Afternoon activities will
feature a vascular symposium, an up-to-the-minute

presentation on diabetes, and a new development
in the debate on “Medical vs. Surgical Manage-
ment of Thyroid Disease.”

Thursday’s program will give new dimensions
to a problem that has dogged practitioners for
centuries, a legal aspect that in recent years had
haunted every physician, and a phase of medicine
that largely has been misunderstood by practi-
tioner and public alike. “Death with Dignity” is
the title of the panel discussion leading off this
interest-packed last day. Featured are a Jesuit
theologian and professor of ethics, a surgeon who
is a former president of both the American Medi-
cal Association and the American Cancer Society,
and the assistant director of the Sloan-Kettering
cancer hospital in New York. The priest will offer
a far from inflexible viewpoint on the matter of
artificially prolonging the lives of hopelessly ill,
suffering patients.

Melvin Belli, one of the Coast’s most famous
trial lawyers whose fame was made largely in mal-
practice litigation, will throw light on the legal
pitfalls that beset the practitioner of medicine.
A campaigner for closer ties between medicine and
the law, Belli not only will expose traps but will
press for assistance from the medical profession
against errant practitioners.

“The Forensic Pathologist — Sherlock Holmes or
Social Scientist?” is the title of the concluding
presentation. In it, the medical examiner of Los
Angeles County will outline the expanding role
of the coroner or medical examiner, and his need
for a new “image.”

Many of the formal lectures will be borne out
graphically by the 152 scientific exhibits on display
in the 90,000 square-foot Exhibit Hall. Other time-
ly subjects to be presented in the exhibits are
“Medical Aspects of Environmental Radiation”
and “The Physician in Investigation of Fatal Air
Accidents.” Fields serving medicine — pharmaceuti-
cal houses, instrument supply and equipment com-
panies, medical publishers and infant-food manu-
facturers— will introduce family doctors to their
newest products by means of technical displays
that will fill the remainder of the huge Exhibit
Hall.

The Assembly social calendar will be climaxed
on the night of April 11 by the President’s Recep-
tion and Dance, which will immediately follow the
inauguration of President-elect Dr. Janies D. Mur-

167

168

Journal of Iowa Medical Society

March, 1962

phy, of Fort Worth, Texas, successor to Dr. Floyd
C. Bratt, of Rochester, New York. For Academy
wives, there will be a complete ladies’ program,
featuring an advice-laden lecture on “How to
Please Your Doctor Husband” by a professional
speaker who specializes in feminine arts and
graces.

We hope many Academy members from Iowa
are making plans to attend this annual National
Assembly, not only for the education it has to offer
but also for a well-earned vacation in a sunny spot.

GP Refresher Course

Television put 131 physicians at the surgeon’s
side during three surgical demonstrations on
Tuesday, February 13, at the State University of
Iowa General Hospital. The physicians, attending
a postgraduate refresher course, watched the dem-
onstrations on television monitors three floors be-
low the operating room where the closed-circuit
telecasts originated.

With the television camera linked to a surgical
microscope in the final demonstration, the physi-
cians had the same microscopic view as the sur-
geon, Dr. John A. Gius, as he gave short presenta-
tions of practical technics used in working with
small structures. From any seat in the Medical
Amphitheatre, the physicians could easily see the
procedures on one or more of the six monitors
equipped with 23-inch screens. They could also
hear the commentary of the surgeon as he carried
out the demonstration.

Dr. Robert T. Tidrick, professor and head of sur-
gery, was in the amphitheatre to provide addi-
tional comments at times and to relay questions
from the viewers to the surgeon by an intercom-
munication system while the demonstrations were
in progress.

Concealed cables now link several areas of the
General Hospital and the Medical Research Cen-
ter into a television network that is expected to
have increasing value as an aid to medical teach-
ing, both on the undergraduate and postgraduate

Running a test on the new closed-circuit television network at the State University of Iowa Medical Center are Dr. John A. Gius,
professor of surgery (holding the intercommunication phone), and Don E. Boyle, junior medical student (looking through the micro-
scope). The television camera is linked to the microscope, and the picture on the small studio monitor is exactly what Boyle sees as
he looks through the microscope. Surgical demonstrations were telecast on February 13 for physicians attending a postgraduate
refresher course at S.U.I.

Vol. LII, No. 3

Journal of Iowa Medical Society

169

levels. Much of the planning for the new televi-
sion system was done by Dr. Gius and Don E.
Boyle, a junior medical student from Perry.

Demonstrators at the annual Refresher Course
for the General Practitioner were Dr. Gius, pro-
fessor of surgery; Dr. David A. Culp, professor of
urology; and Dr. Nicholas P. Rossi, associate in
surgery. The day-long sessions which were held
from Tuesday through Friday, February 13-16,
were devoted to surgery, pediatrics, obstetrics and
gynecology, and internal medicine.

The following Iowa physicians registered dur-
ing the first day of the postgraduate course:

Dean F. Koob, Algona; C. G. Wuest, Amana;
John A. Caffrey, Ames; John L. Bailey, Anamosa;
C. E. Douglas and Norman C. Knosp, Belle Plaine;
Glenn J. Hruska, Belmond; Earl J. Houghton, Bet-
tendorf; J. O. Moermond, Buffalo Center; Harry
N. McMurray, Burlington; Don H. Penly, Cedar
Falls; James R. Flynn, Jr., Carlton B. Lake, Rob-
ert C. Locher, E. B. McConkie, Julius Pietrzak,
James J. Redmond, J. A. Smrha, C. H. Stark,
David Thaler, John F. Troxel, Robert W. Veley,
Cedar Rapids; Edward E. Schmeidel, E. J. Goen,
Charles City; E. M. Mark, Clarksville; Sidney
Brownstone, Clear Lake.

J. R. Jowett, Clinton; John C. Nolan, Corning;
Howard G. Beatty, Creston; Eugene E. Lister, Dal-
las Center; Gordon A. Flynn, J. R. Shorey, Daven-
port; John Hess, Jr., George Kern, Des Moines;
Wallace H. Ash, Leander H. Schafer, DeWitt; J. L.
Saar, Donnellson; A. R. Powell, Elkader; Carlyle

C. Moore, Emmetsburg; J. W. Castell, James H.
Turner, Fairfield; J. B. Thielen, Fonda; Charles L.
Dagle, Dan S. Egbert, E. M. Van Patten, Fort
Dodge; L. G. Schaeferle, Gladbrook; J. C. De-
Meulenaere, Grinnell; Herbert Neff, Guthrie Cen-
ter; E. M. Downey, Guttenberg.

Asa S. Arent, Nelle Schultz, Humboldt; C. R.
Eicher, A. C. Garvy, L. H. Jacques, Harry R. Jen-
kinson, K. J. Judiesch, Wayne J. Tegler, Iowa
City; John L. Mochal, Independence; G. D. Bul-
lock, Inwood; William A. Seidler, Jr., Jamaica;

D. G. Sattler, Kalona; John W. Saar, B. D. Van
Werden, Keokuk; F. P. Ralston, Knoxville; Paul
Ferguson, Lake City; S. M. Haugland, Lake Mills;
H. L. Pitluck, Laurens; George J. Zibilich, Lone
Tree; Wilton J. Willett, Manchester; John M. Hen-
nessey, Manilla; J. A. Broman, F. J. Swift, Jr.,
Maquoketa; H. E. Sauer, Ivan H. Sheeler, Mar-
shalltown; Robert W. Myers, O. E. Senft, Monti-
cello; Byron E. Peterson, Mt. Pleasant; Gordon
Rahn, Robert A. Sautter, Mt. Vernon; Warren
Swayze, Edward R. Wheeler, K. E. Wilcox, Musca-
tine; John D. Conner, Nevada; W. R. Vaughan,
New London; Richard E. H. Phelps, New Sharon;
Robert J. Kaufman, Newton; L. A. Miller, North
English.

Myron R. Hausheer, Oakland; John Hubiak,
Odebolt; R. S. Jaggard, Oelwein; E. B. Gross-
mann, Orange City; R. B. Isham, Osage; Sidney A.

Smith, Oskaloosa; R. J. Peterson, Panora; Stewart
Kanis, Pella; Allen M. Cochrane, Perry; J. M.
Rhodes, Pocahontas; H. C. Bastron, Red Oak; Roy
G. Klocksiem, Rockwell City; Merlin U. Broers,
Schleswig; T. J. Carroll, Sibley; DeWayne C. An-
derson, Stanhope; Norman J. Elmer, Sumner;
G. M. Dalbey, Traer; Edward J. Liska, Ute; Don
C. Weideman, Vinton; L. E. Weber, Jr., Wapello;
Eugene Smith, Waterloo; T. M. Mast, Washington;
James G. Widmer, Wayland; George A. Paschal,
Webster City; R. B. Widmer, Winfield.

The Emerging Pattern of
Urban Histoplasmosis*

Urban children, because of their more localized
environment and less frequent exposure, appear
to be more suitable subjects than rural children
for studies of the acquisition of Histoplasma cap-
sulatum infection. Three sources of infection
among urban children have been reported: visits
to farms or prior rural residence, exposure in ur-
ban structures contaminated by bird droppings,
and importation of contaminated farm soil or man-
ure as fertilizer.

A fourth source of infection consists of wooded,
open park areas contaminated by bird droppings.

Mexico is a city of 15,000 people in each central
Missouri. During the second week in April, 1959,
similar illnesses characterized by chills, high fever
and cough developed in four boys there. The clin-
ical features and chest x-ray findings led the hos-
pital radiologist to suspect histoplasmosis. Positive
skin and serologic tests later confirmed the diag-
nosis.

All four had had onsets of illness within 12-14
days after March 28, 1959, when 64 Boy Scouts
had worked together clearing a large city park.
Since it was probable that a large proportion of
the Scouts in Mexico had been exposed to the in-
fection, arrangements were made through the or-
ganization for further investigations. An epidemi-
ologic questionnaire was completed by 113 boys,
but not all were willing to have skin and serolog-
ic tests and x-ray examinations.

TESTS PERFORMED

The standard used in skin testing was of a
potency equivalent to standard histoplasmin. Two
complement-fixation tests were performed, histo-
plasmin being used as antigen in one and whole-
yeast phase organisms in the other. X-ray films,
14 by 17 in., were evaluated by physicians ex-
perienced in the interpretation of chest films.

Soil samples were collected on several occasions
from the park suspected as the source, and were
cultured for H. capsulatum.

The site of the epidemic was a part of 11 acres

* Abstracted from an article by M. L. Furcolow, F. E. Tosh,
H. W. Larsh, H. J. Lynch, Jr., and G. Shaw, in the new Eng-
land journal of medicine, June 15, 1961.

170

Journal of Iowa Medical Society

March, 1962

on which a large, plantation-type home, built be-
fore the Civil War, is located. The house has fallen
into disrepair, and the grounds have been con-
verted into a pasture for livestock. The grounds
had been completely untended for 15 or 20 years,
and had become heavily overgrown with brush
and trees. The city of Mexico had grown around
the property, so that the park now lies near the
center of the city.

In December, 1958, when the city began clear-
ing the property, it was described as a jungle,
with dense underbrush and vines among large
trees. Leaves and debris were at least several
inches deep. Since about 1950 the park had been a
favorite roosting place for starlings. By the sum-
mer of 1955, thousands of these birds inhabited
the park, and their droppings almost completely
covered the ground. Because of the noise of the
birds and the disagreeable odor, the local res-
idents had undertaken eradication measures. De-
spite a marked decrease in the bird population,
there still were large quantities of bird droppings
at the time of the epidemic.

HISTOPLASMIN RESULTS

Of the 64 boys who had worked in the park, 62
(97 per cent) had positive histoplasmin tests, 36
out of 60 (60 per cent) had positive complement-
fixation tests for histoplasmosis, and 28 out of 60
(47 per cent) had active lesions on x-ray. Of a
group of boys who had not worked in the park,
only 41 per cent had positive skin tests, 25 per
cent had positive complement-fixation tests, and 25
per cent had active lesions on x-ray films. It ap-
pears that practically all of the exposed, sus-
ceptible boys became infected. It is not surprising
to find a number with evidence of H. capsulatum
infection, even though they did not work on the
property, because Mexico lies within a highly en-
demic area. Furthermore, the central location of
the park favored casual visits and exposures.

Only 10 of the boys who had worked in the
park gave histories of clinical illness. Nine of that
number had positive histoplasmin skin tests and
serologic and x-ray findings. In the other boy, only
the skin test was performed, and it was positive. In
five of the 10 boys, a moderately severe illness
had developed, lasting from one to six weeks, with
symptoms of chills, fever, cough, malaise and chest
discomfort. The other five reported symptoms of a
mild upper-respiratory-tract infection lasting a
few days.

Sixty-two per cent of all soil samples collected
from this property were positive for H. capsu-
latum by culture, an unusually high yield. There
is little doubt that the fungus was flourishing
abundantly throughout a large portion of the park
site.

The question arose of whether the frequency of
isolations from the park represented an unusual
prevalence of the fungus in that specific place, or
merely a high prevalence throughout the entire

area. Thus, soil samples were collected from six
selected sites within a radius of three miles from
the city of Mexico and in the city itself. Only one
of the soil specimens was positive for H. cap-
sulatum. It is clear, therefore, that the frequency
of isolations from the park was unique, and not in
any way typical of similar sites in the same gen-
eral area.

The Public's Responsibility in
Emergency Medical Service

A recent survey of the experience of the Emer-
gency Medical Service in Monroe County, New
York, reveals some pertinent facts regarding pub-
lic attitudes. The survey covered the first four
months that the service was in operation, Septem-
ber, October, November and December, 1960, and
also September, 1961, which was used as a check
month.

Of 592 calls during the five-month survey period,
85 (about 15 per cent) reported a serious enough
emergency to require hospitalization of a patient.

Of the 592 callers, 286 reported that they had no
family doctor. Another 110 (or 18 per cent) ad-
mitted having made no effort to reach their family
doctor before calling the Emergency Medical Serv-
ice. Only 46 of them (8 per cent) had tried and
had been unable to reach their family doctor.

The following guide lines were laid down for
defining a true emergency: (1) bleeding that can’t
be stopped; (2) interference with breathing; (3)
convulsive seizure; (4) acute pain; (5) sudden
unconsciousness without quick recovery; (6) high
temperature for no apparent reason; (7) severe
coughing.

The following specific abuses were revealed by
the survey:

1. Patients calling while under the influence of
alcohol.

2. Failure of parents to instruct babysitters in
the procedure for calling the family doctor in the
event of a medical emergency.

3. Patients who have a family doctor but, for
a variety of personal reasons, do not care to call
him.

4. Patients who call for routine medical advice
or treatment, though they have family doctors and
their situations don’t constitute true medical emer-
gencies.

Subsequently, the Monroe County (New York)
Medical Society undertook to publicize a couple
of pieces of good advice:

1. Elderly people whose family physician has
retired should take care to establish a relationship
promptly with another doctor. Newcomers to a
community should regard making the acquaint-
ance of a physician as one of the important steps
in their getting settled.

2. Parents should instruct babysitters, prefer-
ably in writing, about the procedure for calling
their doctor in case of a medical emergency.

THE DOCTORS BUSINESS

Hedging Against the
Effects of Inflation

HOWARD D. BAKER

Waterloo

The major function of life insurance is, in the
event of the death of the head of a family, to pro-
vide financial protection for the dependents. But
“ordinary life” and “endowment” policies have a
second function — to make the policyholder accu-
mulate some savings. These are represented by
the cash or surrender values, and part of each pre-
mium helps to build them up.

We have never recommended life insurance for
investment purposes, yet ordinary -life and endow-
ment policies represent, in part at least, fixed-dol-
lar investments which our clients should take into
account as they do their investment planning.

Most investors recognize that inflation seriously
erodes the purchasing power of their savings ac-
counts, bonds and similar holdings, year after year.
The data reflecting developments in the life insur-
ance industry, however, strongly indicate that the
majority of investors haven’t yet realized the ex-
tent to which prolonged inflation erodes the use-
fulness of life-insurance savings.

Between 1940 and 1959, more than $130 billion
of buying power has been lost by life insurance
policyholders who misplaced their trust in a de-
preciating dollar. The accompanying table illus-
trates the year-by-year losses. Over those 19 years,
the buying power of every life insurance policy in
existence in 1940 was halved!

The men who bought ordinary-life or endow-
ment policies prior to 1940 have life-insui’ance sav-
ings accounts that are capable of purchasing only
half as much goods as they were expected to buy,
and inflation is continuing. Those men have a
choice of two alternatives: (1) to double their

life insurance protection, or (2) to risk having
their families exist on half as much protection as
they planned for them in 1940. A return to prewar
dollar values in the foreseeable future is prac-
tically impossible.

What can the life insurance buyer do to prevent

a recurrence of this problem? How can he provide
for approximately stable protection as the dollar
continues to erode? Though a portion of any life
insurance program certainly should consist of per-
manent, level-premium policies, the inflation that
is bound to continue makes it unwise to place all
of one’s funds in high-premium endowments, an-
nuities and limited-pay insurance plans. Until the
economics of life insurance change to keep pace
with our economy, more emphasis must be placed
upon various types of term protection. A plan of
permanent insurance (ordinary or whole-life) for
strictly permanent needs, and term insurance for

ANNUAL LOSSES IN INSURANCE VALUES
1940-1958

Insurance in Force
Year ( Billions of Dollars)

Loss in

Purchasing Power
( Per Cent)

Loss to
Policyholders
( Billions of Dollars)

1940

$1 1 1.6

1.00

-$ 1.116

1941

1 15.5

8.93

- 10.314

1942

122.2

8.32

- 10.167

1943

127.7

3.22

- 4.112

1944

137.2

2.10

- 2.881

1945

145.8

2.19

- 3.193

1946

151.8

- 1

5.34

- 23.286

1947

170.1

8.28

- 14.084

1948

186.0

2.72

- 5.059

1949

201.2

1.98

+ 3.984

1950

213.7

5.52

- 11.796

1951

234.2

5.48

- 12.834

1952

253.1

.88

- 2.227

1953

276.6

—

.70

- 1.936

1954

304.3

.52

+ 1.582

1955

333.7

.35

- 1.168

1956

372.3

2.80

- 10.424

1957

412.6

2.96

- 12.213

1958

458.4

—

1.70

- 7.793

-$130,064

171

172

Journal of Iowa Medical Society

March, 1962

all temporary needs must be strictly adhered to.

In addition to a basic insurance program, it is of
utmost importance that the intelligent investor
“insure his insurance dollar” by putting as many
additional sums as possible into variable-dollar
commitments such as investment funds, individual
stocks, or other comparable securities. This meth-
od of “balancing” will provide at least a degree of
protection against dollar shrinkage in the years
to come.

In this age of decreasing values, it becomes
doubly important to act upon the advice of com-
petent counsel in all matters. Before embarking
upon a full-scale insurance program or making
substantial changes in your present program, it
will be well worth your while to get a well-quali-
fied individual to analyze your insurance program
and your insurance needs completely.

Is There Anything Else I Can
Do for You?*

Many of you may have read with interest the
article hy Dr. John A. Gius, professor of surgery
at S.U.I., in the February 4 issue of this week
magazine. For those of you who missed it, and for
those who will re-read it happily, we wish to re-
print Dr. Gius’ excellent, thought-provoking
“ Words to Live By.”

A few weeks ago a young intern, after helping
me to perform a difficult examination upon a pa-
tient, asked, “Now, is there anything else I can
do for you, Doctor?”

The feeling of sincere interest and concern in his
unexpected remark had a profound effect on me.
It made me think about the business of doctoring,
where the concepts of service, devotion, dedica-
tion, honesty and loyalty to people who are in
trouble should be taken for granted. It appears,
however, that over the years some of these values
have been worn thin; some have actually been
abandoned, and some have been perverted in pur-
suit of the “fast buck” or that much-publicized ab-
straction, “status.”

Among every other variety of person as well
as doctors, I have sometimes observed a disturb-
ing tendency to think first of “What is there in it
for me?” “Why become involved?” and “I have
other more important things to do.” As a result,
performance tends to become standardized and
superior accomplishments are neither expected,
demanded or achieved.

I think that our traditional ideals have not been
completely lost but that they have simply been
crowded out of our lives by more “practical”
motivations. We are so busy and so concerned
with our own personal affairs that we often over-

* Reprinted from this week magazine. Copyright 1962 by
the United Newspapers Magazine Corporation.

Dr. J. A. Gius

look the opportunity to serve and appear to sub-
scribe to the “couldn’t care less” creed. So we
tend never to give more than the occasion re-
quires.

In order to use our abilities and talents to the
fullest degree and more nearly achieve fulfillment
as individuals and as a society, wouldn’t it be a
good idea to ask the question more often; “Now,
is there anything else that I can do for you?” And
really mean it?

Sports Medicine Newsletter

“Medicine in Sports,” a newsletter devoted ex-
clusively to reporting the latest information on
the care and prevention of athletic injuries, is now
being distributed to all physicians interested in
the subject. Physicians are invited to send their
requests to Charles Stanton, Editor, “Medicine
in Sports,” c/o the Rystan Company, 7 North
MacQuesten Parkway, Mount Vernon, N. Y.

The publication, which has been regularly avail-
able until now only to physicians in the Eastern
states, is intended to fill a gap created by the
rapidly growing interest in sports medicine. Al-
though many professional journals cover the sub-
ject intermittently, “Medicine in Sports” regularly
provides rapid summaries of material in the litera-
ture, provides coverage of meetings and symposia
on a nationwide basis, and prints exclusive articles
by authorities in the field.

The January issue, which covers the recent
meeting of the AMA Committee on the Medical
Aspects of Sports, is still available on request,
according to Mr. Stanton.

STATE DEPARTMENT OF

COMMISSIONER

HEALTH

Morbidity Report for Month of
January 1962

Diseases

1962

Jan.

1961

Dec.

1961

Jan.

Most Cases Reported
From These Counties

Diphtheria

Scarlet lever

304

195

231

Des Moines, Jefferson,
Johnson, Polk

Typhoid lever

Smallpox

Measles

382

217

250

Buena Vista, Crawford,
Iowa, Polk

Whooping cough

1 1

Scott

Brucellosis

Cedar, Scott, Wapello

Chickenpox

Meningococcic

446

359

1,017

Buena Vista, Dubuque,
Polk, Story

meningitis

Lee

Mumps

253

356

577

Black Hawk, Dickinson,
Polk

Poliomyelitis

Infectious

Guthrie

hepatitis

199

148

Black Hawk, Floyd,
Johnson, Mills, Polk

Rabies in animals

Cedar, Des Moines,
Hardin, Jackson,
O'Brien

Malaria

Psittacosis

Q fever

Tuberculosis

For the state

Syphilis

100

For the state

Gonorrhea

134

For the state

Histoplasmosis

Warren

Food intoxication
Meningitis (type

325

unspecified )

Diphtheria carrier

Aseptic meningitis 1

Polk

Salmonellosis

Tetanus

Chancroid
Encephalitis (type

unspecified j
H. influenzal

meningitis

Amebiasis

Fayette

Shigellosis

Polk

Influenza 7,858

Des Moines, Polk, Shel-
by, Washington

USPHS Influenza Surveillance Report
February I, 1962

Epidemics of respiratory disease attended by in-
creased school absenteeism are currently prevalent
throughout the Midwestern and Southeastern
states. Following the first Midwestern identifica-
tion in Missouri and Southern Illinois, epidemic
influenza B spread to involve Eastern Kansas,
Western Kentucky, Central Tennessee, and North
Georgia. This week, in addition to further spread
within these states, a marked increase in reported
outbreaks has occurred in the neighboring states
of Ohio, North Carolina, Arkansas, Minnesota,
Wisconsin, Iowa, North Dakota, and Nebraska. On
the periphery of this epidemic activity, scattered
outbreaks were noted in South Carolina, Alabama,
Indiana, Wisconsin, Oklahoma, and Texas.

Scattered outbreaks of acute febrile respiratory
disease were noted in the northeastern United
States. Increased school absenteeism and/or respir-
atory disease outbreaks were observed in southern
Maryland (3 counties), New Jersey (8 counties),
Pennsylvania (2 counties), Connecticut (2 coun-
ties), Massachusetts (2 counties), Vermont (2
counties), and New York (2 counties).

The epidemic has waned in the Pacific Coast
states and is evidencing little spread in the Rocky
Mountain area.

Influenza B has now been confirmed by virologic
isolation or serologic titer rises in outbreaks in 18
states and the District of Columbia. Additional
states reporting confirmations this week include
Ohio, Minnesota, North Carolina, Wisconsin, Kan-
sas, Iowa, and Utah. No evidence of influenza A
activity has yet been uncovered.

A number of outbreaks have been reported in 3
Canadian provinces: Alberta, British Columbia,
and Manitoba. Epidemics of respiratory disease
confirmed as influenza B are occurring in Poland,
Spain, Denmark, and the United Kingdom.

Deaths from pneumonia and influenza in 108
United States cities remain elevated above expect-
ed levels for the fourth consecutive week. Excess
mortality this week is recorded in 3 of the 9 geo-
graphic divisions of the country.

As of February 9, the infection has spread to all
areas of Iowa. Elementary and secondary school
pupils are the first in a community to become ill in
large numbers. Later the infection spreads to
adults in the community. The Public Health Ser-

173

174

Journal of Iowa Medical Society

March, 1962

vice Communicable Disease Center at Kansas City,
Missouri, whose personnel helped in the study
made at Hazelton, Buchanan County, has reported
the isolation of type B influenza virus from cul-
tures obtained at Hazelton. Dr. Albert McKee, of
the WHO Regional Influenza Laboratory at Iowa
City, has reported serologic confirmation of type
B influenza in University students at Iowa City.

Infectious Hepatitis Summary
Iowa — 196 1

For a period following 1952-1954, when infec-
tious hepatitis rates increased to a high level na-
tionally and when Iowa reported 3,619 cases and
the highest rate for any state in 1954, the numbers
of reported cases decreased throughout the United
States until about 1959, when another definite na-
tional increase was noted. Our own Iowa rates
remained low in 1959, but began to increase in
1960. By 1961, the number of cases reported in
Iowa had increased so as to give the state an in-
fection rate of 70.1 per 100,000 persons and to
place it in the top 10 states with highest infection
rates.

The following summaries give the cases and
deaths, by year, for a period encompassing the
last two waves of infection. The second table lists
the 69 Iowa counties from which cases were re-
ported in 1961, and the number of cases reported
from each of them for that year.

INCIDENCE IN 1962

Through the week ending February 3, a total
of 256 cases of infectious hepatitis have been re-
ported. Although the infection remains widely
scattered, Floyd County has reported the most
cases per thousand of population. Most of those
cases have appeared in the Rudd-Rockford-Marble
Rock School District. Using the combined resourc-

es of the State Department of Health and the U. S.
Public Health Service’s Communicable Disease
Center at Kansas City, we are making a special
study of the infection in that area.

Year

Cases

Deaths

Year

Cases

Deaths

1949

1956

370

1950

1 1

1957

177

1951

1958

201

1952

755

1959

167

1953

1,81 1

I960

460

1954

3,619

1961*

1,986

1955

967

* Through November.

INFECTIOUS HEPATITIS. IOWA— 1961

County

Cases

Adair

Adams

Appanoose

Audubon

Black Hawk

Boone

356

Bremer

Buchanan

Buena Vista

Butler

Carroll

Cass

Cedar

Cerro Gordo .

Cherokee

Chickasaw

Clay 2

Crawford

Dallas

Davis . . .

Des Moines

Dubuque

Fremont

Greene

Grundy

Guthrie

Hamilton

Hancock

Harrison

Henry

low^j

Jackson I

Jasper

Jefferson

County

Cases

Johnson

Jones 1

Kossuth

Lee

Linn 12

Lucas

Madison

Mahaska

Marion

. 15

Marshall

Mills

Muscatine

. . . . 10

O'Brien

Page

Plymouth

Polk

520

Pottawattamie . . . .

. . . . 125

Poweshiek

Sac

Scott

. . 214

Shelby

Story

. . . . 10

Union

Van Buren

Wapello

Warren

. 64

Washington

Wayne

Webster

. . . . 12

Winnebago

Woodbury

135

Worth

Wright

Abstracts of Articles on
Venereal Diseases

Since 1957, infectious syphilis has been increas-
ing alarmingly, and physicians who had not seen
a single case of infectious syphilis in 20 years have
begun finding it among their patients. Unfortu-
nately, little information on the disease appears
in the widely circulated medical publications.

To alleviate this situation, the Venereal Dis-
ease Program of USPHS routinely abstracts cur-
rent articles on venereal diseases from almost
1,000 journals, both foreign and domestic, for a
publication entitled current literature on vene-
real disease which it distributes three of four
times a year and indexes annually.

It will be sent regularly, free of charge, to phy-
sicians who request it. Address Dr. William J.
Brown, chief, Venereal Disease Branch, USPHS
Communicable Disease Center, Atlanta 22, Geor-
gia.

Vol. LII, No. 3

Journal of Iowa Medical Society

175

Rabies Diagnosis

On January 1, 1938, the State Hygienic Lab-
oratory initiated the mouse inoculation test as a
routine procedure to be performed on all rabies
specimens that were microscopically negative. It
was the first state public health laboratory to in-
itiate that procedure. On January 1, 1960, a com-
parative study was begun in an effort to evaluate
the fluorescent antibody technic (FRA) in the
diagnosis of rabies. After one full year of com-
parison, it was found that FRA is as reliable as
the mouse-inoculation procedure that had been
considered the court of last appeal. Thus, the Lab-
oratory contemplates discontinuing the direct
microscopic test and continuing, for the time be-
ing, to perform mouse tests on all FRA-negative
specimens. If the reliability of the FRA technic
continues, the mouse test may be discontinued,

too. The following table presents the Laboratory’s
experience with the above-named tests:

Direct Microscopic - +

Mouse Inoculation + +

FRA +

Where the direct microscopic test has been neg-
ative, about 12 per cent have proved positive both
on mouse inoculation and by FRA. Where the di-
rect microscopic test has been positive, both
mouse inoculation and FRA have been positive.
Where the FRA has been negative, both the di-
rect microscopic and the mouse-inoculation tests
have been negative.

Thus it appears that the FRA test is highly
specific and, in addition, is comparatively rapid,
for it can be completed in less than 24 hours,
whereas the mouse test requires 10-30 days to
complete.

Rabies in Animals in Iowa in 1961

COUNTy DISTRIBUTION BY SPECIES OF REPORTED CASES*

Legend Cases

S-Skunk 221

C-Cattle 72

A-Cat . 35

D-Dog 10

F-Fox 4

H-Horse 2

B-Bat 2

T-Rabbit I

G-Goat I

U-Unknown I

Total 349

cNeii^

Our President Says —

The English translation of a statement of the
Roman philosopher Marcus Aurelius comes to my
mind in preparing my letter for you this month:

“Time is a sort of river of passing events —
and strong is its current. No sooner is a thing
brought to sight than it is swept by, and an-
other takes its place. Then this, too, will be
swept away.’’

There have been many important events this
year, worthwhile projects accomplished, and still
other challenges to be developed. Already it is
time for you who are officers and chairmen to
prepare an account of your year’s accomplish-
ments.

The Annual Meeting committee met January 11
at the home of Mrs. Frank Coleman, in Des
Moines. In spite of the severe winter weather,
Mrs. A. C. Richmond, of Fort Madison, and Mrs.
L. V. Larsen, of Harlan, were in attendance. It is
their intent to develop and plan a stimulating, in-
formative and entertaining meeting. Watch for
the program in the April auxiliary news.

Is your Auxiliary promoting the Essay Contest?
Are you scouting about to find eligible candidates
for the Volunteer Health Service Award in your
county? Make sure that your county’s selection is
nominated for the state award. Special recognition
will be given to the county essay contest winners
and volunteer health service honorees at the An-
nual Meeting of the Woman’s Auxiliary.

Those of you who attended the Iowa Auxiliary
WHAM campaign meeting, February 20, in Des
Moines, considered it an outstanding Auxiliary
experience. We are indebted and grateful to our
Iowa Medical Society and our own Legislative
chairman, Mrs. Howard Ellis, for planning the
occasion and enabling us to become informed on
the problems and policies of the medical profes-
sion.

Let’s put our shoulders to the wheel and prove
that we are the Women who Help American Med-
icine!!

— Gertrude F. Kilgore, President

Give to the American Medical
Education Fund

Tips for Safety

MRS. R. H. MOE

Fires are caused by:

1. Smoking in bed

2. Matches and cigarette lighters accessible to
small children

3. Frayed electrical cords

4. Overloaded electrical circuits (Fuses blow
repeatedly.)

5. Poorly vented heating systems

6. Absence of protective grills for exposed space
heaters and radiators

7. Cluttered basements, attics and closets.

Tips on Fire Prevention

8. Store flammable liquids and oily rags in tight-
ly-closed metal containers.

9. Empty ashtrays into closed metal containers
or into the toilet. Use large, deep ashtrays.

10. Check the cost of installing a fire alarm in
your home. It’s inexpensive insurance.

11. Flameproof the drapes and curtains in your
home, or have your cleaner do it.

ARE YOU ALWAYS A LADY IN TRAFFIC?

Were you as courteous as you could have been
when you drove to the shopping center today?

1. Are you as courteous to other drivers sharing
the road wTith you as you are to guests in your
home?

2. Are you thoughtful of other drivers in sig-
nalling your intention to change direction — or
change lanes?

3. Do you maintain your poise and dignity when
facing everyday driving irritations?

4. Are you considerate of pedestrians — alert to
help the handicapped or elderly?

5. Do you try to make your passengers as com-
fortable as possible by offering a smooth, safe
ride?

6. Are you aware of the safety of other mothers’
children, when driving your child to or from
school, or do you double park or crowd the cross-
walk, endangering others by obstructing necessary
vision?

176

These 6 points may save you 12 points against
your driving record.

Vol. LII, No. 3

Journal of Iowa Medical Society

177

COUNTY AUXILIARIES

BLACK HAWK

Thirty-five members of the Black Hawk County
Auxiliary met January 16 at the home of Mrs.
F. Harold Reuling, in Waterloo, for an interesting
program. They heard Mr. M. J. Kitzman, artist
instructor at West High School, Waterloo, give
an analysis of contemporary painting. Despite the
exploitation of such groups as the “action paint-
ers,” who have made most people despair of
learning what modern art is all about, there are
some true modernists, and Mr. Kitzman identified
them and explained what they have sought to
produce. He showed slides to point out an orderly
sequence in the development of what is called
modern art. With great integrity and the serious
conviction about painting that sets his own works
far above those of the ordinary painter, he helped
restore a respect for painting to the dubious and
provided a renewal of inspiration for those already
devoted to the subject of art.

Final plans for the annual Medicine Ball were
made at the January meeting. This highly suc-
cessful event, held during February, will be re-
ported at a later date.

MARION

The Woman’s Auxiliary to the Marion County
Medical Society held its January meeting at the
home of Mrs. A. N. Schanche, in Knoxville, with
10 members present.

Mrs. D. A. Mater, president, conducted the busi-
ness meeting. Bylaws for the newly organized
Auxiliary were read, discussed and adopted. The
members agreed to sponsor a Future Nurses’ Club
as their project for the coming year.

The 1962 officers are as follows: president, Mrs.
D. A. Mater; vice-president, Mrs. D. H. Hake; sec-
retary, Mrs. A. W. Byrnes; treasurer, Mrs. F. P.
Ralston; historian, Mrs. A. N. Schanche; publicity
chairman, Mrs. T. D. Clark; corresponding sec-
retary, Mrs. W. D. Rosborough; and parliamen-
tarian, Mrs. G. M. Arnott. All of the officers are
from Knoxville.

The Auxiliary planned a farewell dinner for
Mrs. Clyde Nicholson, a charter member, who is
moving to Des Moines on March 1. The dinner
will be held at the Maple Buffet.

WAPELLO

The Auxiliary joined the Wapello County Medi-
cal Society for a dinner meeting at the Country
Club, in Ottumwa, on February 6. The doctors
were hosts at the social hour for 150 guests, and
after dinner both they and their guests listened
with great interest to a talk on “Socialized Medi-
cine in England.” The speaker, Daniel B. Stone,
M.D., a native Englishman who is now an asso-

ciate professor in the Department of Internal Med-
icine of the Medical College at the State Univer-
sity of Iowa. His talk was uniquely presented, and
the audience seemed willing to agree with him
that the U. S. would not be content to accept the
lower standards of medicine now existing in Eng-
land.

Community Health Service Award

Have YOU selected the candidate your Auxili-
ary considers deserving of recognition for her
interest in health and health-education in your
community? This is an excellent public relations
project in which you, as an Auxiliary, can partici-
pate. Each county Auxiliary or member-at-large
may nominate a woman for the statewide award.
Send in the name as soon as possible after March
10, so that the judges at the state level will have
ample time for reviewing and judging. The winner
will be announced and the award presented at the
Annual Meeting in May.

This citation is presented yearly to a lay woman
for her interest and activity in the health field.
The candidate should not be a member of a doc-
tor’s family, a nurse, or anyone else whose em-
ployment includes the particular service for which
she is to be recognized. That is, her health work
must have been done on a volunteer basis.

After your selection is made:

1. Send a report of her activities in your com-
munity to me.

2. Include a brief history of the individual her-
self.

3. Submit your candidate’s name and a short
summary of her activities to your local newspaper,
radio and TV stations. In this way, many fine
women will be given some publicity for their good
work in their own community.

Have a meeting soon — get busy on this project —
you just might have a winner living next door.

Margaret Stauch (Mrs. Omar)
Service Award Chairman
1823 Summit Street,

Sioux City, Iowa

Operation Coffee Cup

As an individual or as an Auxiliary, are you
participating in this project? Your continued ac-
tivity in opposition to the King-Anderson Bill is
important. Contact your county Auxiliary presi-
dent or legislative chairman, or the president of
your county medical society, for the Ronald
Reagan record to be used at your coffee. Several
records are available in each county. Many Auxil-
iaries and individual members have played the
record for various groups. Mrs. C. A. Trueblood,
first vice-president of the State Auxiliary, held a
series of coffees recently in her city of Indianola.

Have you participated? If so let us have a re-
port.

178

Journal of Iowa Medical Society

March, 1962

'Meals on Wheels" at Ottumwa

“Meals on Wheels,” now a permanent and val-
uable service within the Ottumwa city health pro-
gram, grew out of a joint experiment by the Pub-
lic Health Needs Advisory Committee and the
Ottumwa Hospital. Miss Anna B. White, public
health nurse in Wapello County, began it by rec-
ommending that one hot, well-balanced meal per
day be provided to a home-bound elderly woman
who was unable to cook for herself. A local res-
taurant prepared the meal, and it was delivered
by a boy from the rehabilitation office.

A delivery problem and other sorts of difficul-
ties eventually developed, but a report from the
Public Health Nursing Service stressed the need
for continuing and expanding the service. For the
next several months, Miss White and others spoke
before local groups on the need for and the feasi-
bility of the plan. Finally, Mr. Richard Schreiber,
administrator of Ottumwa Hospital, offered to
have his institution prepare and deliver hot noon
meals to five persons selected by the public health
nurses and approved by the individuals’ doctors.
Starting on July 3, 1961, the project was con-
tinued daily for four weeks, at a cost of 50c per
meal to each recipient — the estimated cost of the
meal to the Hospital.

Response from the patients was overwhelmingly
favorable, and the public health nurses said that
the patients receiving the service showed consider-
able improvement in general appearance and in
morale.

On September 15, the service became a per-
manent public health project in Ottumwa. It is
thought to be the only such service in Iowa. At
present, 10 persons are served noon meals in their
homes. Meat and two vegetables are placed on a
three-compartment Pyrex plate in the hospital
kitchen, and the meal is transported in a “meal
pack," an electrically heated vacuum container
that can be carried like a suitcase. No bread, des-
sert, salad or drink is included. The hospital per-
sonnel who deliver the meals are paid for the
gasoline they use.

One of the chief problems associated with start-
ing the service was the cost of the “meal packs.”
Two-plate containers, although half again as ex-
pensive ($30 vs. $20), eliminate the “call back”
problem. Delivery and container costs have been
paid for by voluntary contributions from com-
munity organizations.

Both the Nursing Service and the Hospital are
pleased with the success of this new type of care.

Miss White says that one of the biggest problems
at present is that of extending the program to
those elderly persons living alone who do not eat
adequate meals and feel that they cannot afford
the service.

Special lists of articles on “Meals on Wheels”
are available from the SUI Institute of Gerontol-
ogy, Iowa City.

In Memoriam

“Henceforth there is laid up for me a crown of
righteousness, which the Lord, the righteous
judge, shall give me at that day” II Timothy 4:8

Mrs. D. F. Crowley, Sr., Des Moines
Mrs. H. C. Willett, Des Moines
Mrs. R. J. Porter, Des Moines

Helping Others

It was good news to hear again from the Leprosy
Relief Fund. Here is a quote from Mr. Aitken’s
most recent letter:

“Drugs came from Mrs. Lemon of Oskaloosa
and other areas of Iowa.

“In fact, Iowa has helped us a great deal in our
work and your efforts are much appreciated.”

It is such a thrill to hear this! A special “thank
you” from Iowa Auxiliaries to Mrs. Lemon, presi-
dent of the Mahaska County Auxiliary, and oth-
ers for sustaining us in this good work!

It would be exciting if someone from Iowa
could go to Thailand and visit this leprosy colony
which Dr. Orr deemed so deserving. This seems
quite possible since Mr. Aitken mentions that he
had a visitor from Texas — Iowans travel too!

Those of us who have no prospects of making
such a trip must content ourselves with helping
to further the work. So far, each county Auxiliary
must assume shipping costs, and do its own solicit-
ing and shipping. We do not have shipping cost
relief from any existing agency that has this
privilege. Perhaps sometime we can accomplish
this. Meanwhile, let us help America and the
AMA by sharing. Send all excess drug samples
to:

Mr. Adam Aitken
Leprosy Relief
Box 1283

Bangkok, Thailand

WOMAN’S AUXILIARY TO THE IOWA MEDICAL SOCIETY

President — Mrs. B. F. Kilgore, 5434 Woodland, Des Moines 12
President-Elect— Mrs. A. C. Richmond, 1132 Avenue A, Fort
Madison

Recording Secretary — Mrs. F. L. Poepsel, West Point
Corresponding Secretary— Mrs. N. W. Irving, Jr., 4916 Har-
wood Drive, Des Moines 12

Treasurer — Mrs. J. H. Matheson, 4321 California Drive, Des
Moines 12

Editor of the news — Mrs. Herbert Shulman, 101 Martin Road,
Waterloo

IOWA MEDICAL SOCIETY

SUI COLLEGE OF MEDICINE ISSUE:

• Shock Management, page 1 85

• Listeriosis in the Newborn, page 192

• Artificial Kidney, page 199

• Rupture of the Pregnant Uterus,

page 207

• Blood Oxygen at Birth and Subsequent

Psychological Test Scores, page 212

• Clinical Pathologic Conference,

page 2 I 7

U.C. MEDICAL
APR :

CENTER L! TRACY

9 1962

A (

I IAt

San Francisco, 22

(paramethasone acetate, Lilly)

Iii acute cases of ALLERGY,
Haldrone produces rapid re-
mission of symptoms with little
adverse elfect on electrolyte
metabolism.

This is a reminder ad-
vertisement. For ade-
quate information for
use, please consult
manufacturer's litera-
ture. Eli Lilly and
Company, I nd ian-
apolis 6, Indiana.

240030

Suggested daily dosage in hay fever:
Initial suppressive dose. . 4-8 mg.
Maintenance dose .... 2-4 mg.

Supplied in bottles of 30 , 100 , and
500 tablets:

1 mg.. Yellow (scored)

2 mg.. Orange (scored)

APRIL, 1962

because
vitamin ' :
deficiencies §
tend to be
multiple... \
give your
chronically ill
patient the
protection of

high-potency vitamin formula with minerals

It is generally accepted that diseases of long standing and
other conditions of physiologic stress may produce a need
for additional vitamins, myadec is designed to supply that
need. Just one capsule a day provides therapeutic potencies
of 9 vitamins, plus selected minerals normally present in
body tissues, myadec is also useful for the prevention of
vitamin deficiencies in patients whose usual diets are lacking
in these important food factors.

Each myadec capsule contains: Vitamins: Vitamin Bi2,
crystalline— 5 meg.; Vitamin B2 (riboflavin)— 10 mg.; Vita-
min B6 (pyridoxine hydrochloride)— 2 mg.; Vitamin Bi
mononitrate— 10 mg.; Nicotinamide (niacinamide)— 100 mg.;
Vitamin C (ascorbic acid)— 150 mg.; Vitamin A— (7.5 mg.)
25,000 units; Vitamin D-(25 meg.) 1,000 units; Vitamin E
(d-alpha-tocopheryl acetate concentrate)— 5 I.U. Minerals
(as inorganic salts): Iodine— 0.15 mg.; Manganese— 1 mg.;
Cobalt— 0.1 mg.; Potassium— 5 mg.; Molybdenum— 0.2 mg.;
Iron— 15 mg.; Copper— 1 mg.; Zinc— 1.5 mg.; Magnesium—
6 mg.; Calcium— 105 mg.; Phosphorus— 80
mg. Bottles of 30, 100, and 250.

PARKE-DAVIS

PARKE, DAVIS & COMPANY, Detroit 32. Michigan

Vol. LI I APRIL, 1962 No. 4

CONTENTS

Dedication: Walter Lawrence Bierring, M.D. . 179

Retirement: Harry M. Hines, Ph.D 181

New Department Heads:

Dermatology, Robert G. Carney, M.D. . . 181

Physiology, C. A. M. Hogben, M.D 182

Pediatrics, Donal Dunphy, M.D 183

SCENTIFXC ARTICLES
Current Concepts of Shock Management

Edward E. Mason, M.D., and Robert T. Kunau,

Jr., Iowa City 185

Listeriosis in the Newborn
Irvin S. Snyder, Ph.D., and Herbert P. Miller,

Jr., M.D., Iowa City 192

Extracorporeal Dialysis in Renal Failure
Richard C. Hockmuth, M.D., Luke C. Faber,

M.D., and Edward E. Mason, M.D., Iowa City 199

Rupture of the Pregnant Uterus
James H. Frudenfeld, M.D., and Clifford P.

Goplerud, M.D., Iowa City 207

Correlation Between Cord Blood Oxygen Values
and Psychological Test Scores
Donal Dunphy, M.D., Iowa City, and Vivian
Pessin, Buffalo, New York 212

State University of Iowa College of Medicine
Clinical Pathologic Conference 217

EDITORIALS

Doctor, How Is Your Biopsy Technic? .... 228

The Case of the Misused Catheter 229

Rare Diseases 230

The Use of Urinary pH Can Be Important . 230

Annual University Issue 231

SPECIAL DEPARTMENTS

Coming Meetings 226

President’s Page 232

1962 Annual Meeting of the Iowa Medical Society 233

Journal Book Shelf 245

Iowa Chapter of the American Academy of Gen-
eral Practice 249

State Department of Health 250

County Medical Society Officers 254

In the Public Interest Facing page 254

The Doctor’s Business 255

Iowa Association of Medical Assistants .... 257

Woman’s Auxiliary News 259

The Month in Washington xxx

Personals xxxiii

Deaths xlv

MISCELLANEOUS

Eye Color and Skin 184

The Lift in the Shoe 191

IMS Nominating Committee Meeting .... 198

Blank Hospital Pediatric Conference .... 248

All-Out Federal Effort to Develop Cold Vaccines 258

Hospital Costs and the Physician xlv

Local Medical Societies Launch Public Service Ads xlvi

Vitamins — Charms or Nutrients? xlvii

Public Relations — Their Cause and Cure ... lii

EDITORS

Dennis H. Kelly, Sr., M.D., Scientific Editor Des Moines

Edward W. Hamilton, Ph.D., Managing Editor

Des Moines

SCIENTIFIC EDITORIAL PANEL

Walter M. Kirkendall, M.D Iowa City

Floyd M. Burgeson, M.D Des Moines

Daniel A. Glomset, M.D Des Moines

Robert N. Larimer, M.D Sioux City

Daniel F. Crowley, M.D Des Moines

PUBLICATION COMMITTEE

Samuel P. Leinbach, M.D Belmond

Otis D. Wolfe, M.D Marshalltown

Cecil W. Seibert, M.D Waterloo

Richard F. Birge, M.D., Secretary Des Moines

Dennis H. Kelly, Sr., M.D., Editor Ex Officio Des Moines

Address all communications to the Editor of the Jour-
nal, 529-36th Street, Des Moines 12

Postmaster, send form 35 79 to the above address.

The Faculty of the S. U. I. College of Medicine
Dedicates the Following Papers to the Memory of

Walter Lawrence Bierring, M.D.*

Dr. Bierring, the grand old man of American med-
icine, is dead. He whose life seemed inextinguish-
able and who had risen more than once from a
grave illness, is no longer among us. The plain fact
of his mortality is set before us to contemplate. He,
who seemed to have captured the well hidden
secret of Ponce de Leon and embodied youthfulness
in great antiquity has departed in the ninety-third
year of his age. With his death one of America’s
strongest links with British and Continental medi-
cine of the Nineteenth Century is broken. No long-
er do we have the beneficence of the urbane wis-
dom and humanity of this grand old man who
managed to retain a young outlook, despite his
venerable years which he wore with dignity but
without solemnity.

I first encountered the name Walter L. Bierring
and the magnificent handwriting in which it was
embodied on the Alpha Omega Alpha certificate
which I received as an undergraduate student at
the University of Virginia more years ago than I

* Reprinted from the pharos, July, 1961, pages 184 to 187.

Walter Lawrence Bierring, M.D.
July 15, 1868— June 24, 1961

like to recall. I heard of him intermittently there-
after and was aware of his contributions to med-
ical education, to the establishment of firm stand
ards for practice and for licensure, and his work
with the American Medical Association. Only
when I came to Iowa thirteen years ago did I fall
directly under his spell. He had been head of the
Department of Internal Medicine of the College of
Medicine, Iowa City, from 1903 to 1910. After much
urging he wrote a book telling the story of our
Department of Medicine which happened to be
just two years younger than Dr. Bierring.

It was my pleasure to be closely associated with
Dr. Bierring. He usually came down to Iowa City
for the AQA initiation each year. He recited the
Hippocratic Oath with the new members, and
often talked of the history of the society, or of
medical history as he knew and lived it. I made at
least four pilgrimages with him for the installation
of new chapters of the AUA including Oklahoma,
Arkansas, Missouri and the Albert Einstein Medi-
cal School.

I think many undergraduate medical students
shared my delight in the inspirational recollections
Dr. Bierring was able to evoke of memorable days
in the Pasteur Institute, of working in Koch’s
laboratory, visits and studying at the famous Ger-
man schools and his visits to Britain. He was able
to share with us intimate knowledge of many of
medicine’s heroic figures. Possessing as he did
great natural advantages in mind and character,
his habits and attitudes guaranteed for them full
employment. He exemplified the rare phenomenon
of productivity which increased rather than dimin-
ished with the years. Not for him was just the old
man’s dreaming of dreams but also the seeing of
visions. Finally combining the zest of youth and
the wisdom of years Dr. Bierring escaped the bane
epitomized by La Rochefoucauld who said, “Old
men are fond of giving good advice in order to
console themselves for being no longer able to
serve as bad examples.”

Dr. Bierring’s career may be divided, perhaps
somewhat arbitrarily, into the phases of student,
teacher, consultant, and elder statesman. He told
me that he helped pay for his education by his
penmanship, going around to fairs and other cele-
brations where he would draw elegant birds on
elaborately ornamented scrolls, or write with
many flourishes a person’s name suitable for hang-
ing in the Victorian parlor of the day. Even before
he finished medical school his talents were well

179

180

Journal of Iowa Medical Society

April, 1962

recognized and he had been appointed to take over
the chair in the Department of Pathology and
Bacteriology by the Board of Regents a few weeks
before he received the M.D. degree on 9 March
1892. This he did after two exciting years when
he studied in Heidelberg in Koch’s laboratory, in
Vienna with Billroth, and at the Pasteur Institute
with Pasteur, Metchnikoff and Roux. One impor-
tant result of such thoroughgoing and practical in-
struction was his introduction at Iowa of the newer
methods of staining bacteria, the routine use of
the microscope and the manufacture of the first
antitoxin produced in this country west of New
York City.

Early in his career Dr. Bierring narrowly es-
caped tragedy when, after a lump was discovered
in his left leg with enlargement of the inguinal
lymph nodes, the diagnosis of epithelioma was
made and the leg amputated. Later on there was
strong suspicion that the diagnosis might be in
error but this blow was merely a challenge. His
artificial leg stimulated rather than thwarted his
talent for travel.

Dr. Bierring became head of the Department of
the Theory and Practice of Medicine at the State
University of Iowa after he had been in charge of
Bacteriology and Pathology for eleven years. His
many clinical papers during this period indicate
that he was diligently applying the technical
knowledge gained to the clinical problems he en-
countered. In 1910 he left Iowa City and for three
years was connected with the medical school at
Drake. For the next two decades Dr. Bierring
practiced as a medical consultant in the emerging
specialty of internal medicine. He was greatly in
demand. During this time he was pioneering in the
establishment of standards for licensure for the
practice of medicine. He was busily engaged in
prodding the public about such important matters
as proper sewage disposal, pure water supply and
the control of infections upon which our urban life
so largely depends. He helped establish the Na-
tional Board of Medical Examiners and was influ-
ential in changing the form of clinical teaching by
the introduction of practical bedside examination
of patients as part of the requirement for certifica-
tion by the National Board of Medical Examiners.

Dr. Bierring can properly be called the father
of Alpha Omega Alpha since, though he did not
found it, it was through his thoughtful and con-
structive work that it reached its full stature as a
symbol of distinguished excellence in medicine.
As president of Alpha Omega Alpha for 36 years
and editor of the pharos Dr. Bierring saw the
unprecedented growth of American medicine with
great improvement in quality of research, scholar-
ship and practice. Members of Alpha Omega Alpha
may be proud that through his wise statesmanlike
control this growth has been not only very exten-
sive in scope but very fruitful in encouraging ex-
cellence.

It was fitting that in recent years after retiring

from the directorship of the Iowa State Depart-
ment of Health he assumed responsibility for the
Division of Gerontology and Cardiology.

Thus Dr. Bierring grew with the years. Despite
his preoccupation with matters of aging he paid no
attention to any hypothetical conflict between gen-
erations. He wasted no time, as many older people
tend to do, scowling at the activities and antics of
the young. Rather he advanced our understanding
of how the great potential for effective enterprise
and even creative achievement are not the prerog-
ative of youth but constitute a challenge to those
whose years but not whose capacities rank them
as old men.

Perhaps Dr. Bierring’s character can be summed
up best in a story which Dr. Peyton Rous once
told me, which I have related elsewhere: “It oc-
curred at the time when the cornerstone of the
University Hospitals building was laid in Iowa
City in the middle 1920’s. The great ceremonial
occasion was attended by representatives from
many universities and institutions. As Dr. Bierring
and Dr. Rous were being driven to the affair to
hear the great speakers, they came upon the scene
of an accident. A runaway horse had overturned
a wagon, and a young farmer lay injured. Dr. Bier-
ring immediately got out and attended to the med-
ical needs of the injured man, while the procession
moved on without him. Only when the injured
man was cared for did Dr. Bierring, unruffled and
unaware of the impression he had made, move on
to the pavilion of the elect where the speeches
were in progress.”

Others have listed the many marks of distinc-
tion, the numerous memberships, honors, and offi-
ces in the outstanding medical societies which came
Dr. Bierring’s way. He accepted them with good
grace but without any notion that they conferred
infallibility. The essence of Dr. Bierring’s contri-
butions was his vision of the larger aspects of med-
icine, its potential grandeur and the value of en-
couragement of scholarship, seeking out the best
in learning, in teaching, in research and in prac-
tice. His several missions accomplished, Dr. Bier-
ring died in the fullness of years, ripe in wisdom,
mellow in the knowledge of history so much of
which he himself had seen at first hand. American
medicine may well take pride in a person whose
accomplishments are worthy of the heroes of old.
We all share with his family the sorrow inevitable
with bereavement, and we sympathize with the
members of his family who survive him, but this
sorrow happily is tempered by our contemplation
of his great achievements, his wisdom and his
character.

— William B. Bean, M.D.

REFERENCES

Bierring, Walter Lawrence: President of Alpha Omega

Alpha from The Pharos, 6:3-4, 1943.

Bierring, Walter L.: A Golden Epoch in American Medi-
cine, the William W. Root Lecture, The Pharos, 16:12-21,
1952.

Bean, William B.: An Appreciation, Walter L. Bierring,
M.D., Geriatrics, 16:355-359, 1961.

Vol. LII, No. 4

Journal of Iowa Medical Society

181

Retirement

After 17 years of deft and dedicated steering of
the Department of Physiology at the SUI College
of Medicine, Dr. Harry M. Hines retired as head
of his Department in July, 1961.

One should underscore the “his,” because during
the years under his direction, the Physiology De-
partment showed a phenomenal growth in number
of graduate students, and in its reputation as an
excellent training ground for young people eager
to teach and to carry on research in the biological
sciences.

The “vital statistics” on Dr. Hines are, of course,
available in American men of science, so they need
not be repeated here at any length. He was born
in Spencer, Iowa, and received his undergraduate
and graduate training at SUI — B.A. in 1916, M.S.
in 1917, and Ph.D. in Biochemistry in 1922. Be-
tween earning his M.S. and his Ph.D., he served in
the Armed Forces in World War I. Thereafter he
went “up the ladder” in the Department of Physi-
ology, serving as instructor, assistant professor,
associate professor and, in 1936 and subsequent
years, as professor. He was appointed head of the
Department in 1944, succeeding Dr. John McClin-
tock, and served in that capacity until his retire-
ment in July, 1961.

Dr. Hines holds memberships in several profes-
sional societies, and has been honored on several
occasions for his research into problems relating
to physical medicine. He also serves on the edi-
torial board of the American journal of physical
medicine. His research interests cover many as-
pects of physiology, and he has made many im-
portant contributions, through personal and di-
rected research, to the areas of nerve and muscle

Harry M. Hines, Ph.D.

degeneration and regeneration, diseases of muscle,
peripheral circulation and blood flow; and he has
directed pioneer work in the physiologic effects of
microwaves.

The writer of the above paragraphs first became
associated with Dr. Hines in 1940, as a brand-new
Ph.D., to work with him on problems of neuro-
muscular regeneration, under a grant from The
National Foundation for Infantile Paralysis, and
the work went on for the next 10 years. Those
were rugged, busy years — but, in retrospect it is
clear that an old observation was vindicated: A
young scientist may not realize it at the time, but
service under a tough, hard-to-satisfy mentor con-
stitutes a superlative atmosphere in which to grow
up and to form critical, honest and productive
habits of mind.

Dr. Hines always had, and still has, a deep per-
sonal interest in each graduate student who re-
ceived a degree in the Department of Physiology.
He actively recruited students, saw to it that they
were supported and trained in the best possible
manner, and continued to follow their careers with
an avid interest after they left SUI. He “kept in
touch.”

Dr. Hines’ many colleagues and former students
continue to regard him, after his retirement, as a
wise and sympathetic counselor and friend.

John D. Thomson, Ph.D.
associate professor of physiology

New Head of Dermatology

Robert G. Carney was born April 25, 1914, in Ann
Arbor, Michigan, the son of Robert J. Carney and
Frances Sweet Gibson. His father, Robert J. Car-
ney, was a professor of chemistry and director of
the Chemistry Stores Department at the Univer-
sity of Michigan. On June 18, 1939, he was united
in marriage with Dorothy Ann Briscoe at Ann
Arbor, Michigan. Their family of four children in-
cludes Robert, aged 19, and three daughtei’s, Pa-
tricia, aged 17, Kay, aged 15, and Peg, aged 13.

Dr. Carney was educated in the public grade
and high schools in Ann Arbor, and obtained an
A.B. degree cum laude from the University of
Michigan in 1935. His M.D. degree was confen-ed
by the same university in 1939, and during his col-
lege work he was elected to membership in Phi
Beta Kappa and Phi Kappa Phi honor societies. He
was also a member of Galens, a medical honor so-
ciety, and Phi Rho Sigma frateinity. His internship
was at the State University of Iowa Hospitals,
1939-40, and a residency in dei’matology and syph-
ilology followed from 1940 through 1943.

For some thirty -nine months, from 1943-1946, Dr.
Carney served in the Medical Corps of the U. S.
Naval Reserve on active duty, first at USN Hos-
pital, Farragut, Idaho, and later at USN hospitals
in New Guinea and Western Austi'alia. For a time
he was medical officer aboard the USS Clytie AS

182

Journal of Iowa Medical Society

April, 1962

26 (Submarine Tender) based at Freemantle,
Western Australia, and New London, Connecticut,
and following his severance from the USS Clytie
he was a medical officer until his discharge at
USN Hospital, Great Lakes, Illinois.

He was appointed an associate in dermatology
and syphilology, and held that position from 1946
to 1947. His professorial appointments were as fol-
lows: assistant professor in 1947; associate profes-
sor in 1951; and professor in 1954. He has held the
post of attending dermatologist at the Veterans
Administration Hospital, Iowa City, from 1952 un-
til the present. His appointment as professor and
head of dermatology and syphilology was made on
February 1, 1961.

His society memberships include the following:
Johnson County Medical Society, American Medi-
cal Association, Iowa Dermatological Society, Iowa
Clinical Medical Society, Chicago Dermatological
Society, Society for Investigative Dermatology,
American Academy of Dermatology and Syphilol-
ogy, and the American Dermatological Association.
He is, at present, on the membership committee of
the American Dermatological Association, holding
a six-year appointment.

Dr. Carney is also a member of the U. S. Pharm-
acopoeia Committee of Revision and chairman of
the U.S.P. advisory panel on dermatology. He is
also a member of the Committee on Cosmetics of
the AMA and of the Advisory Committee to the
Food and Drug Administration, and is a dermato-
logic consultant to the Council on Drugs and to the
National Better Business Bureau. In addition, he
is a former chairman and present member of the
Iowa Medical Bulletin, a member of the Scientific
Exhibits Committee of the Iowa Medical Society,
and the University, and a member of the Hospital
Records Committee and Formulary Committee.

Robert G. Carney, M.D.

In addition to his other accomplishments, Dr.
Carney has written numerous scientific articles
and with Dr. Nomland is the co-author of a book,

DERMATOLOGY FOR THE STUDENT AND PHYSICIAN, pub-
lished in 1955. His teaching ability, administrative
talents, discerning clinical judgment, ready wit,
and affable personality have made us happy and
proud at his selection as professor and head of the
Department of Dermatology and Syphilology.

C. E. Radcliffe, M.D.

associate professor of dermatology

and syphilology

New Head of Physiology

On September 1, 1961, Charles Adrian Michael
Hogben, M.D., Ph.D., assumed the duties of profes-
sor and head of the Department of Physiology at
the State University of Iowa College of Medicine,
succeeding Dr. Harry Hines, who retired after
serving in this same capacity for 17 years.

Dr. Hogben was born on November 21, 1921, in
Buckinghamshire, England, and became a citizen
of the United States in 1944. He received the de-
gree of bachelor of science in 1941, and the degree
of doctor of medicine in 1943 from the University
of Wisconsin. Following graduation from medical
school, he served as an assistant in the Department
of Physiology at the University of Wisconsin from
1941 through 1943, and became a teaching assistant
in the same department in 1943. Following an in-
ternship at the Philadelphia General Hospital, he
entered the Medical Corps of the United States
Army, where he served for a period of two years.
Upon release from military service, he became a
fellow in medicine at the Mayo Clinic, where he
served for a period of four years. During that

C. A. M. Hogben, M.D.

Vol. LII, No. 4

Journal of Iowa Medical Society

183

period he worked in the areas of clinical medicine
and physiology, and the degree of doctor of philos-
ophy was conferred upon him in 1950 by the Uni-
versity of Minnesota.

During 1950, Dr. Hogben was a National Re-
search Council fellow in medical science at the
Zoophysiology Laboratory in Copenhagen, Den-
mark. After that year abroad, he returned to this
country to become medical officer in the Section
on Kidney and Electrolyte Metabolism of the Na-
tional Heart Institution in the National Institutes
of Health at Bethesda, Maryland, where he served
until his appointment as head of the Department of
Physiology at the State University of Iowa.

In addition to the appointment at the National
Institutes of Health, he was a research associate in
medicine at the George Washington University
Medical School, and a guest lecturer in the De-
partment of Physiology at the University of Min-
nesota, where he offered a course in gastrointes-
tinal physiology.

Dr. Hogben is a member of the American Physi-
ological Society, Phi Beta Kappa, Sigma Xi, the
Philadelphia Physiological Society, and the Med-
ical Society of the District of Columbia. He is the
author or co-author of numerous scientific articles
which have been published in the principal physio-
logic and medical journals.

New Head of Pediatrics

Dr. Donal Dunphy assumed his duties as profes-
sor and head of the Department of Pediatrics at
the SUI College of Medicine on September 1, 1961,
succeeding Dr. W. W. McCrory.

Dr. Dunphy was born in Northampton, Massa-
chusetts, on February 24, 1917. He received his
bachelor of arts degree in 1939 from Holy Cross,
and his doctor of medicine in 1944 from the Yale
University School of Medicine. Following comple-
tion of his basic medical studies, he served an in-
ternship and a residency in the New Haven Gen-
eral Hospital, and was appointed instructor in the
Department of Pediatrics at the Yale University
School of Medicine in 1947, where he served for a
period of three years. Afterward, he entered the
private practice of pediatrics in Stratford, Con-
necticut, and was attending pediatrician at the
Bridgeport General Hospital. Simultaneously, he
served as a part-time fellow in the Department of
Pediatric Cardiology at the Yale University School
of Medicine until he entered the military service
in 1953.

He served for two years in the U. S. Army
Medical Corps in Landsthul, Germany, as pediatric
consultant for the United States Army, European
Theater. Upon completion of his military duty, he
was appointed associate pediatrician at the Uni-
versity of Buffalo School of Medicine in 1955. In
1956 he was elevated to assistant professor in the
same department and served in that capacity until

Donal Dunphy, M.D.

1959. During that period he was appointed director
of the Child Growth Study, director of the Out-
patient Department, and director and co-investi-
gator of the Child Development Program, a col-
laborative project of the National Institutes of
Health and the National Institute of Neurological
Diseases and Blindness at the Childrens Hospital
in Buffalo. In 1959 he became associate professor
in the Department of Pediatrics at the University
of Buffalo School of Medicine, and held that title
until his appointment as professor and head of the
Department of Pediatrics at the University of
Iowa. He is a member and diplomate of the Amer-
ican Board of Pediatrics, and has published nu-
merous articles in pediatric and other outstanding
medical journals.

YOU'LL HEAR ABOUT

Casualties in nuclear-weapon warfare
at the

ANNUAL MEETING OF THE IOWA
MEDICAL SOCIETY
May 13-16

Veterans Memorial Auditorium, Des Moines

184

Journal of Iowa Medical Society

April, 1962

Eye Color and Skin

Brown eyes appear to predominate in patients
with atopic dermatitis, skin disease due to familial
allergic tendencies, reports Dr. Robert G. Carney
of the Department of Dermatology, University of
Iowa, Iowa City.*

Studies conducted at two intervals during the
past 10 years seemingly confirm this impression.
Almost two-thirds of the patients with atopic skin
diseases have had brown eyes, while the incidence
of brown eyes in three control groups was only
about two-fifths.

When the incidence of brown and hazel eyes was
tabulated against the incidence of blue, green and
gray eyes, “those with atopic dermatitis showed
an incidence of 64 per cent brown and hazel eyes.

. . . When eye colors were grouped in 3 classes
— the brown, the blue, and the hazel-green-gray
in-betweens — and compared, the same marked
preponderance of brown showed up in the atopic
dermatitis group, 56 per cent of the whole, against
34 per cent or 35 per cent in the controls,” Dr.
Carney said. “Perhaps eye color serves as a rough
index of skin pigmentation.” The skin of dark
skinned persons tends to become leathery and
hardened more readily “and perhaps the darker
skinned white person is more prone to atopic
dermatitis, or more prone for the disease to last
longer.”

The University Dermatology Clinic at Iowa now
is recording eye color in all patients, trying to de-
termine whether there may be other skin diseases
prone to go along with brown or blue eyes. Skin
pigmentation in relation to other skin diseases also
will be studied, the author said.

In a discussion following the paper (presented
at the annual meeting of the American Dermato-
logical Association), Dr. A. Fletcher Hall, of Santa
Monica, Calif., related Dr. Carney’s findings to
racial differences. He pointed out that “brown-
eyed individuals are more likely to be a mixture
than the blue-eyed. The blue-eyed people are more
likely to indicate an Anglo-Saxon or Nordic in-
heritance, whereas the brown-eyed will most like-
ly represent one or more Mediterranean, Latin,
Gallic, or Oriental strains.

“The personality patterns, or the emotional pat-
terns, of the blue-eyed group of races . . . are
recognized as being different in a great many ways
from those of the brown-eyed races. The brown-
eyed races, I believe, are more likely to have emo-
tional and personality patterns which would lend
themselves to neurogenic or psychogenic condi-
tions. Whatever factor there may be of a psycho-
genic or neurogenic nature in atopic dermatitis
would be more likely to be found, I believe, in
the races that one ordinarily associates with brown
eyes.”

* Carney, R. G.: Eye color in atopic dermatitis, archives
of dermatology 85:57, (January) 1962.

The AMA Annual Meeting

By LEONARD LARSON, M.D.

President, American Medical Association

Each year at this season it is customary for the
president of the American Medical Association to
extend an invitation to all American physicians
to attend the AMA’s annual meeting. Each year
it is also expected of the president to state that
“this year’s meeting will be the best yet.”

This year I have no hesitation in proclaiming
that the 1962 Annual Meeting June 24-28 in Chi-
cago will be an excellent scientific session that
will offer much solid, comprehensive information
that will be of great value to those of us in the
practice of medicine.

Dr. Samuel P. Newman, chairman of the Council
on Scientific Assembly, and his colleagues, to-
gether with the Council’s new secretary, Dr.
George R. Meneely, has done a splendid job in
studying the entire field of medicine and deter-
mining in which areas there has been substantial
progress worth reporting to the men in practice.

As usual, the program for the meeting is sched-
uled for publication May 19 in the journal of the
ama. You will be able to judge for yourself wheth-
er I am right in saying that the program for the
1962 meeting is the finest ever assembled for the
benefit of the American medical practitioner.

Theme of the meeting will be “Medicine in the
Atomic Age.” This is a broad, generalized theme
that covers everything in medicine. And that is
just what the scientific program will do.

The twenty-one sections concentrating on the
medical specialties are pooling their talents and
resources to bring the top men in the nation to
deliver papers in areas such as Nuclear Medicine,
Mental Health, Tissue Transplantation, Inflamma-
tory and Ulcerative Diseases of the Small Intes-
tine, Inhalation Therapy, Clinical Cardiology and
Anticoagulant Therapy, and Diagnostic Problems
and Exfoliative Cytologic Methods.

And for those of you who swore “never again!”
following the last annual meeting in Chicago in
1956, allow me to point out that the 1962 meeting
will be in the swank new McCormick Place, com-
pletely air conditioned. The steamy heat and
cramped quarters of the old Navy Pier are just
an unpleasant memory.

See you in June in Chicago!

1962 Annual Meeting
IOWA MEDICAL SOCIETY
Veterans Memorial Auditorium
Des Moines
May 13-16

Current Concepts of Shock Management

EDWARD E. MASON, M.D., and
ROBERT T. KUNAU, JR.

Iowa City

Perfusion is the crux of our modern understand-
ing of shock and of its treatment. There are no
radically new ideas, but some basic concepts which
originally were known only to a few people and
which were difficult to test except in carefully con-
trolled laboratory experiments have now become
the basis for bedside treatment. The clinician has
become a practical physiologist and pharmacol-
ogist. He has at his command pharmacologic
agents which are extremely powerful and helpful
if used properly, but which are dangerous if mis-
used.

As is indicated in Figure 1, normal circulation
has as its central theme the distribution and per-
fusion according to tissue needs. Shock is a gen-
eral deficiency of tissue perfusion, which is un-
equal in distribution and duration. There is a re-
distribution of blood flow, with preservation of
perfusion of brain and myocardium through reflex
vasospasm and the influence of circulating norepi-
nephrine. Skin and subcutaneous tissues are defi-
cient in blood flow. In severe hemorrhagic shock
or traumatic shock, important visceral areas such
as the kidney are also devoid of blood flow. As the
flow of blood through tissues is slowed, the blood
loses its suspension stability. There is a clumping
together and even an adherence of cells, with a
separation of cells from plasma. Blood which
should be a sol and a suspension becomes a gel and
a sludge, with a consequent increase in viscosity
and, at times, thromboses in the microcirculation.
In some areas the thrombosis may involve larger

From the Department of Surgery at the SUI College of
Medicine.

vessels, with infarction of wedges of tissue or even,
occasionally, bilateral renal cortical necrosis, com-
plete adrenal infarction, or thrombosis of a pitui-
tary gland. Usually, such severe shock results in
the death of the patient.

Adequate circulation or perfusion of all organs
according to needs is dependent upon an adequate
venous return to the heart. This requires that the
patient have a normal blood volume, and under
some circumstances may require actually an in-
creased blood volume. Shock also may be present
in a patient who has an inadequate volume of
extracellular fluid or even a severe deficiency of

COMPONENTS OF NORMAL CIRCULATION

Di stri burton

* Define Shock Here

Figure I. Shock is a disturbance of normal tissue perfusion
which may result from loss of blood volume, loss of venous
tone, sudden inadequacy in cardiac function, loss of suspen-
sion stability and fluidity of blood, excessive and inappro-
priate vasomotion, or a combination of many of these factors.

185

186

Journal of Iowa Medical Society

April, 1962

total body water. Venous return is dependent
upon support of the veins through intrinsic tone
and through muscular activity within fascial com-
partments of the extremities. As the blood returns
to the heart, it is compressed and reejected into
an elastic arterial tree. During systole, the elastic
arterial tree accumulates some of the potential
energy for continued propulsion of the blood
stream during diastole. This pulsatile flow is con-
verted to a more continuous flow in the microcir-
culation distal to the precapillary sphincter. The
largest blood vessel smooth muscle component is
found in the precapillary sphincters. Neurohumer-
al regulation of these sphincters controls the flow
of blood through regions and small areas of the
vascular bed, and at the same time provides the
peripheral resistance which contributes to the
maintenance of a normal blood pressure. The pre-
capillary sphincters prevent loss of effective blood
volume into a capillary bed that potentially is
greater in capacity than the normal blood volume.

The treatment of shock has as its objective a
restoration of normal perfusion to all of the body
tissues, each according to its need. It is not enough
to reestablish normal blood pressure, for normal
blood pressure is not synonymous with good tis-
sue perfusion. In addition, the patient must have
warm, pink, dry skin. The capillary bed, as seen
through the finger- and toenails, should refill
promptly after compression. The patient should
be alert, and should no longer suffer from thirst
and air hunger. There should be a flow of urine
at least at a minimum rate of four or five drops
per minute.

RESTORATION OF BLOOD VOLUME AND VASOMOTION

In order to establish normal circulation for a
patient who appears to be in shock, the clinician
would do well to consider, in logical sequence,
the items listed in Figure 2. The vast majority of
patients in shock have a deficiency in blood vol-
ume or in extracellular fluid volume, and if these

Shock Therapy?

Restore Perfusion!

Via

Volume
Vasomotion
Velocity and Viscosity
Viability and Cellular Integrity

Figure 2. Treatment ol shock is urgent and requires atten-
tion first to the commonest and most prominent features of
shock. When blood volume and extracellular fluid volume are
normal but the patient's poor tissue perfusion persists, then
attention should be directed toward the less common and
more difficult problems of shock. With time, these latter fac-
tors become the prominent defects of resistant shock. From
the standpoint of frequency of these aspects of shock and of
the time factor in individual patients, this sequence for atten-
tion seems appropriate.

are restored to normal, the other complicating
factors of vasospasm and sludging of blood don’t
usually require any special attention. Physicians
have rightly emphasized the importance of treat-
ing shock with adequate amounts of blood. Many
patients with so-called irreversible shock are
found at autopsy to have died from inadequate re-
placement of blood loss. It would seem better to
risk overtransfusion of a patient than to become
too much concerned with the use of vasopressors
and cortisone, only to find too late that the patient
should have had blood. If blood is not immediately
available for a patient with hemorrhagic or trau-
matic shock, then medium molecular weight dex-
tran may be used. It is important that circulation
be maintained, even through a considerable dilu-
tion of red blood cells. If decreased numbers of
red blood cells are passing rapidly through the
tissues, there will still be adequate oxygenation
and removal of carbon dioxide, as well as an ade-
quate supply of other substrates and the removal
of other wastes. When blood becomes available,
it can then be used. If dextran is used, it is im-
portant to draw blood for cross matching before
one starts the dextran infusion, since the presence
of dextran may interfere with the cross match.

In some patients, it is rather obvious that even
though the blood volume has been restored, the
circulation still remains poor. Then, the next most
common general area for therapeutic consideration
is that of abnormal vasomotion. This can be of two
general types: (1) so-called peripheral vascular

collapse, and (2) excessive vasospasm. An obvious
and common situation for peripheral vascular col-
lapse is that in which a patient has received ex-
cessive amounts of sedation or anesthetic agents.
It may then be necessary to use a vasopressor to
increase the general tone of the vascular system
and to improve venous return to the heart.

If a vasopressor is to be used, it should be an
effective one. Norepinephrine is the natural media-
tor of nerve impulses from the adrenergic nerves
to the smooth muscle of blood vessels. In addi-
tion, it is the natural humoral agent that is re-
leased from the adrenal medulla to provide a
generalized increase in vascular tone. Therefore,
it would seem to be the agent of choice. Because
it is such a powerful agent, its misuse has led to
complications that have made some people afraid
to administer it. If norepinephrine is used in an
intravenous infusion, there is some likelihood of
spasm of the vein and leakage of the solution out-
side of the vessel. The result is a profound local
ischemia of the skin and subcutaneous tissues.
Many instances of slough have been observed,
and some of them have been reported. It was ob-
served that infiltration of such an area with an
antagonist to norepinephrine such as phentolamine
would prevent the slough.

Other agents such as heparin and hyaluronidase
have also been used with adrenolytic agents to
prevent local ischemia in the areas of infiltration.
Experimentally, it has been shown that if 4 to 8

Vol. LII, No. 4

Journal of Iowa Medical Society

187

mg. of phentolamine is mixed with norepinephrine
in the intravenous infusion, necrosis is prevented
when this mixture leaks into the subcutaneous
tissues. In addition, it has been demonstrated that
the blood pressure can be supported just as well
with the mixture of phentolamine and norepineph-
rine as with norepinephrine alone. It thus appears
that phentolamine, at least in the doses required,
is not a complete antagonist of norepinephrine,
but that it does eliminate the undesirable, exces-
sive vasospasm that otherwise occurs locally in
the area of infiltration.

There is reason to believe that some of these
so-called adrenolytic agents have a beneficial effect
on the visceral circulation. Just as they prevent
local slough of the skin, they also seem to prevent
slough of organs. This effect may be analagous
to the phenomenon observed by Wiggers that
sympathetic denervation made animals more sensi-
tive to circulating norepinephrine. In patients who
were receiving larger and larger doses of norepi-
nephrine without regaining a satisfactory blood
pressure, without urine flow, with paleness of the
skin and, in one instance, of a colostomy mucosa,
we have found that adding phentolamine to the
norepinephrine infusion brings about a better
blood pressure, an improved appearance of the
skin (and of the colostomy mucosa) and an almost
immediate resumption of urine excretion. The ad-
dition of phentolamine, moreover, has made it
seem easier to discontinue the norepinephrine.

It is known that norepinephrine alone as an in-
fusion, if given in somewhat excessive amounts,
will lead to a loss of plasma from the blood stream.
This seems to be due to excessive vasoconstriction
in some areas, to ischemia and to the leakage and
sequestration of plasma.

There are many agents which affect the produc-
tion or release of norepinephrine at its areas of
storage in the presynaptic region of the nerves.
The presence or absence of norepinephrine in its
normal areas in nerves seems to influence the
effect of circulating norepinephrine. Without go-
ing into detail, and in fact admitting that little
is known about the actual mechanism of action
of these drugs at the effector level, one can assert
empirically __ that agonists and antagonists have
clifferent effects in different species of animals and
in accordance with the presence or absence of
other drugs and anesthetic agents. Furthermore,
each of these drugs also has different effects at
different dosage levels. It therefore is not surpris-
ing that norepinephrine and a so-called antagonist,
phentolamine, can be mixed in the same solution
so as to achieve a beneficial effect from each of
the drugs and at the same time eliminate certain
deleterious effects through their mutual competi-
tion or antagonism.

RESTORATION OF SUSPENSION STABILITY

If, in the sequence of therapeutic logic, it is con-
cluded that the patient’s shock is no longer a
volume-deficiency problem, and that abnormal

vasomotion is not contributing to the patient’s
poor tissue perfusion, then the next question to
be asked is whether there is a loss of suspension
stability — in other words, a sludging of blood. This
can be answered by examining the scleral vessels
under 40-power magnification, such as the opthal-
mologists use in some of their work.

The microcirculation is said to be greatly dis-
turbed, with many vessels filled with agglutinated
cells and with stagnation of blood. Since equip-
ment to examine scleral vessels is not generally
available, it may be desirable to consider the
possibility of stagnation whenever the aforemen-
tioned abnormalities in blood volume and vasomo-
tion have been excluded and when the patient
still is not excreting urine.

Suspension stability can be reestablished
through the administration of low molecular
weight dextran. This is a dextran of 40,000 average
molecular weight, in contrast to the dextran that
has been generally used in this country, with an
average molecular weight of 70,000. Investigation
of the use of low molecular weight dextran was
carried on initially by Swedish workers. When
dextran first became available, the British tended
to use a rather high molecular weight product,
and the American workers settled for one of medi-
um molecular weight, but still sufficiently high to
make it stay in the vascular bed. It was thought
that if the molecular weight were too low, the
dextran would rapidly leak out of the vascular
bed and would not provide the desired plasma-
expander effect. The low molecular weight dex-
tran is of a size that does leak through the glomer-
ular filter, and consequently it does not expand
plasma volume for a very long period of time in
a normal person. However, the size of the dextran
molecule has other effects. The larger it is, the
more it tends to produce increased viscosity, to
interfere with blood clotting and, perhaps, to
achieve other undesirable effects.

The low molecular weight dextran gives the
greatest plasma expansion in the patient who has
poor kidney function, poor circulation and, in fact,
a tendency toward sludging. It coats albumin and
cells, and coats the endothelium. It carries a
slightly negative charge that probably helps repel
one surface from another. The dextran molecules
are symmetrical and tend not to adhere to one
another. The viscosity of the blood is lowered.
The cells stay in suspension, and the blood flows
much more rapidly through the microcirculation.

Besides providing plasma expansion for a brief
period of time and reestablishing suspension sta-
bility of cells, the low molecular weight dextran
does leak through the glomerular filter and acts as
an osmotic diuretic. There is a great deal of ex-
perimental and some clinical evidence indicating
that an osmotic diuretic alone is a beneficial agent
in patients who are predisposed to ischemic kidney
damage. Mannitol has also been used. The low
molecular weight dextran comes in a saline solu-
tion, and if an osmotic diuresis does occur, the

188

Journal of Iowa Medical Society

April, 1962

concomitant loss of electrolytes is adequately com-
pensated for by the saline in the solution.

CORRECTION FOR MEMBRANE AND CELL FUNCTIONS

If the poor circulation doesn’t seem to be due
to, or fails to respond to therapy for, abnormalities
in volume, vasomotion or viscosity, then one must
consider the possibility of some abnormality in
cell-membrane permeability and cellular metabo-
lism or viability. This is an area in which therapy
is still quite empirical, but where cortisone is the
agent most likely to be effective. There are very
occasional patients in whom there is actually an
adrenal insufficiency either because of adrenal
vessel thrombosis as a part of the shock episode,
or because of a disuse atrophy from a prolonged
period of steroid treatment. In general, however,
hemorrhage does not lead to adrenal insufficiency.
Trauma seldom leads to adrenal insufficiency, and
even a patient with endotoxic shock probably has
normal adrenal function in most instances. How-
ever, there are some patients who seem to re-
spond to massive doses of adrenal corticosteroids.
Such therapy is seldom required in hemorrhagic
or traumatic shock, but it is often required in
endotoxic shock.

There are a number of disease processes in
which cortisone seems to be effective in altering
the permeability of the endothelium. Lipoid ne-
phrosis, pseudomembranous enterocolitis and en-
dotoxic shock may have something in common in
this respect. As one sees patients with endotoxic
shock and pseudomembranous enterocolitis, one
becomes impressed with the concept that these
are variations of the same process. There are
some patients who never have a striking fall in
blood pressure, but who lose large amounts of
fluid from the gastrointestinal tract. There are
other patients who go into profound peripheral
vascular collapse and have no evidence of ab-
normal bowel function.

Undoubtedly some of the differences in the reac-
tions of patients is due to the particular organism
that is producing the endotoxin and to the dosage
of endotoxin that the patient is receiving. There
are also differences in the responses of various
patients. Some have had gastrointestinal opera-
tions. Others have had no surgical procedures.
Some have had antibiotics, and others have had
none. As in the rest of the field of shock, there
are many variables, and it would be most difficult
to prove, in a carefully controlled, scientific man-
ner, with adequate statistical methodology, that
similar patients treated in slightly different ways
show different and treatment-dependent responses.
This is where the incomparable human computer
— the clinician at the bedside, with his vast ex-
perience and with his ability to make overt ob-
servations of the patient’s signs and symptoms
and to assimilate subliminal data — is able to pro-
vide care that may seem, at times, to be more
artistic than scientific.

Empirically, the patient with endotoxic shock
who has received plasma expanders, appropriate
antibiotics and possibly either vasopressors or
adrenolytic agents, or both, and who still does not
appear to be improving should be treated with
massive doses of hydrocortisone, up to one gram
in divided doses on the first day. Such treatment
seems to help reestablish normal function of the
cell membranes. It may bring some fluid out of
cells into the extracellular fluid. It probably
brings protein-rich fluid back into the vascular
space. It may restore normal responsiveness of
vascular smooth muscle. But whatever the mech-
anism, this massive use of hydrocortisone fre-
quently seems to be specific for the patient with
endotoxic shock.

As a part of treating the patient at the cellular
level, one should keep in mind that excessive
fever greatly accelerates metabolism, besides be-
ing the result of increased metabolism, and that
cooling the patient down to a normal temperature
may benefit him by decreasing the excessive de-
mands on his circulatory system and vital organs.
After all, the general problem of shock treatment
is one of providing adequate amounts of oxygen
and substrates to the tissues as they are needed.
If the metabolism of these materials is at an ex-
cessive rate, it alone will lead to an oxygen deficit,
to an accumulation of waste products and to ad-
ditional cellular dysfunction, especially in areas
of poor circulation. General body cooling is not
a panacea, but is an adjunct requiring caution,
skill and either personal experience or familiarity
with the pertinent literature.

In the occasional patient who has been subjected
to very severe or prolonged shock and in whom
tissue damage has occurred, with release of throm-
bokinase and consequent microthrombi, a bleeding
tendency may develop from a deficiency of clotting
factors as part of a generalized intravascular
thrombosis. It may be desirable, under such cir-
cumstances, to treat the patient with heparin.

If the clinician thinks through all of the above
possibilities, he should cover most of the areas
in which he can help the shock patient. He should
not be satisfied with his treatment until adequate
perfusion of all tissues has been reestablished and
is being maintained.

MUCH DEPENDS ON THE PHYSICIAN'S
CLINICAL JUDGMENT

Probably the most controversial area in the
treatment of shock today is that of vasomotion.
For most patients, a clinician who refused to make
use of vasopressors and adrenolytic agents could
still be very effective. Yet, there are a few patients
who need such treatment. This is particularly
true of the traumatized patient who may have a
great excess of reflex vasospasm in addition to
his loss of blood. There even are a few patients
with hemorrhagic shock or cardiogenic shock, and
certainly there are some with endotoxic shock,

Vol. LII, No. 4

Journal of Iowa Medical Society

189

who have abnormal vasomotion as a major prob-
lem.

The use of norepinephrine in a patient who has
an unsatisfactory blood pressure has gained wide
acceptance, even to the extent that some patients
are treated with vasopressors long after they
have demonstrated failure to respond to such
treatment. There is no experimental evidence
specifically to support the use of vasopressors in
the treatment of shock in human beings. Many
animal experiments have been reported in which
hemorrhagic and traumatic shock has been less-
ened, in which animals’ lives have been prolonged,
and in which larger numbers of animals have sur-
vived because of the use of adrenolytic agents.
But there is very little in the literature describing
the use of those antagonists for the treatment of
shock in man. After talking to a few people who
have used such agents in selected cases, and from
limited personal experience, one of us (Dr. Ma-
son) has concluded that these agents have been
helpful, but that it would be very difficult to as-
semble the evidence in such a way as to prove or
defend them against those who condemn them.

It has been very difficult to design experiments
in the animal laboratory to result in the deaths
of dogs called “controls” and in the survival of
dogs treated with specific agents. When actual

LAW OF LAPLACE

Pre- Capillary
Sphincter

End. 23D

Ela. &
Mus,

Fib.

Vein

Neurohumoral
^ Sti mulation

-- *T * P r

Figure 3. Tension in the walls ol vessels may be increased
by neurohumoral stimulation of the smooth muscle component,
and this may improve venous return. The danger of excessive
stimulation consists of closure of precapillary sphincters and
ischemic damage. At any given level of vascular tone, the
blood pressure, distention of vessels and stability of the
system are dependent upon the blood volume. In shock, this
system is unstable, and like a balloon it tends toward the
filling of large-lumen veins and the closure of small-lumen
precapillary sphincters. These are the chief variables, when
one looks at the system as a relatively simple one. Actually,
when the hydraulic factors and the problems of a circulating
suspension of cells are added, the picture becomes even
more complex.

shock patients are treated, there are many addi-
tional variables, and “control” is much more diffi-
cult. No two patients are alike. It would seem that
if agonists such as norepinephrine, and antagonists
such as phentolamine or Dibenzyline are to be
used, they must be used by clinicians with con-
siderable experience in evaluating the severity
of shock and the responses of patients to a variety
of treatments, and that results may need to be
evaluated solely on the basis of clinical judgment
in individual cases, rather than on the basis of
large, statistically sound, “controlled,” randomized
experiments.

The level of serum transaminase determined
serially in patients may be the best index of the
extent of general cellular damage that is occur-
ring and has recently occurred in any given pa-
tient who is successfully treated for shock. The
development of new electronic apparatus for con-
tinuous recording of vital signs and for the anal-
ysis of cardiac output and adequacy of regional
circulation may allow more precise and objective
documentation of the effectiveness of some of
our therapies. Such equipment is not sufficiently
developed, but there is evidence of rapid progress.
In the meantime, the clinician must continue to
do his best to individualize treatment, to use all
modalities that seem to contribute to the improve-
ment of circulation, and to avoid doing harm.

A recent review by Burton of the relationship of
structure to function in the tissues of blood-vessel
walls has suggested the illustration of the law of
LaPlace that is shown in Figure 3. It may help to
explain some of the objectives that seem important
in the treatment of abnormal vasomotion in cases
of shock. The law of LaPlace says that the tension
on the wall of a container is equal to the pressure
on the inner surface of that container multiplied
by the radius. Burton draws an analogy between
the vascular system and a balloon that is partially
distended by air. The partially inflated balloon
tends to be a rather unstable system, tending to
collapse in a given area and to extend to a wide
diameter in others. When the entire balloon is
fully distended, it becomes stable, and if all of the
air is removed, it again becomes stable.

The basic objective in the treatment of shock is
to establish sufficient distention and tension of the
walls of the entire vascular tree so that the whole
system is stabilized and remains open. This, in
turn, should allow a generally adequate blood flow
and perfusion of all tissues. If the vascular bed has
been partially emptied or is relaxed, there is a
reduction of intravascular pressure, and there is
also less tension on the wall of the vessel. The re-
maining blood tends to move into the more dis-
tensible portions of the system, and those portions
of the vascular bed that have the smallest lumens
tend to collapse.

The obvious treatment under such circumstances
would be a redistention of the vascular bed — in
other words, the administration of blood-volume

190

Journal of Iowa Medical Society

April, 1962

expanders. There are other situations in which the
main problem may not be a lack of volume of con-
tained fluids, but a change in the tension on the
walls of the vessels. In peripheral vascular col-
lapse, there is a real need for vasopressors, and the
objective is to increase the tone of the blood vessel
walls to such an extent as to reduce the volume
and to increase the venous return. However, this
must not be carried to the point of occluding the
smaller vessels. As long as precapillary sphincters
do not close and cause ischemia of vital organs, the
administration of norepinephrine is advantageous.
The special sensitivity of vessels in the human
kidney makes observation of kidney function an
extremely valuable part in the evaluation of the
efficacy of vasopressor treatment.

If the only change in the patient is a rise in
blood pressure, following administration of nore-
pinephrine, then some other or additional treat-
ment should be tried. The question of the ade-
quacy of blood volume and extracellular fluid vol-
ume should again be raised. The precapillary
sphincter has a proportionately large amount of
smooth muscle, and has, in addition, a thick endo-
thelial layer. These vessels have small radii. Their
purpose is to provide a normal peripheral resist-
ance and to regulate blood flow through the re-
gional capillary beds. In hemorrhagic shock, and
especially with added trauma, there is marked
neurohumeral stimulation which causes temporary
occlusion of many of the precapillary sphincters
and resultant ischemia of the tissues beyond. This
may be advantageous for a very short period of
time, in that it may keep blood flowing to the brain
and the myocardium, but occasionally, even after
the extreme vasospasm is no longer required, it
may persist and become the chief cause of progres-
sion into irreversible shock. This obviously re-
quires treatment.

At the University of Manitoba, a number of clin-
icians working with Dr. Nickerson have treated
patients with generalized and excessive vasocon-
striction, using the irreversible adrenergic block-
ing agent Dibenzyline. They have observed some
fall in blood pressure. It is greatest in those pa-
tients who actually have deficiencies of total blood
volume. In the patients who have adequate blood
volumes, there is very little fall in blood pressure,
but there is a widening in pulse presure. Such
patients cease to perspire, their skin becomes
warm, and they resume urine output.

In the final analysis, these are the tests of any
treatment of abnormal vasomotion: (1) the ap-

pearance of excellent peripheral circulation and
the indication of good visceral circulation by the
flow of urine; (2) improvement in cerebration;
and (3) a sustained blood pressure, as indicated
by a good pulse and a widening in pulse pressure.

The most difficult to explain of the aspects of
treatment for abnormal vasomotion is the use of
agonist and antagonist, both at the same time. It

seems almost to be wishful thinking to expect that
excessive contraction of the precapillary sphincter
can be eliminated by one agent, and at the same
time that its agonist can be used to increase the
tone of the veins and to mobilize pooled blood in
areas of vascular collapse. At times, it seems that
it would be desirable to remove all the endogenous
neurohumoral stimulation that affects vasomotion.
Clinically, the vasomotion appears to be so greatly
disturbed as to contribute to poor perfusion. Em-
pirically, however, the use of the agonist norepine-
phrine with an antagonist such as phentolamine
seems to result in clinical improvement. The selec-
tive roles of action of agonists and antagonists in
these circumstances are not well understood, but
clinically the response is evident in signs of more
satisfactory tissue perfusion.

SUMMARY AND CONCLUSION

It is noteworthy that the administration of drugs
in the treatment of shock must always be secon-
dary to blood and extracellular fluid replacement
and treatment of the underlying cause of the
shock. The general rule seems to hold that even
with phentolamine added, low doses of norepine-
phrine are tolerated, whereas large doses, if re-
quired to elevate the blood pressure, are indica-
tive of probable ultimate failure of such treat-
ment.

The great challenge to the clinician is to main-
tain his equilibrium in the practice of the art of
medicine, and at the same time to accept his re-
sponsibility in becoming a bedside pharmacologist
and physiologist in order to make appropriate use
of the powerful new tools that he can use in reduc-
ing mortality and morbidity — especially damage to
the kidney.

TREATING VASOMOTION IN SHOCK
Yes

Agonist Blood Volume Antagonist

Venous Return Perfusion Peripheral Resistance

Antagonist Blood Volume Agonist

i I

Venous Return Perfusion Peripheral Resistance

Figure 4. Blood volume replacement is desirable and
necessary to enhance venous return and aid tissue perfusion.
Similarly, the use of an agonist — an agent that causes con-
traction of smooth muscle cells in vessels — is desirable as a
means of augmenting venous return. Excessive peripheral
resistance, by its very nature, can aggravate poor tissue perfu-
sion. An antagonist — an agent that lessens excessive peripheral
resistance — may facilitate tissue perfusion. If the antagonist
leads to a reduction in venous return, or if the agonist in-
creases peripheral resistance and interferes with tissue per-
fusion, then the drug is undesirable.

Vol. LII, No. 4

Journal of Iowa Medical Society

191

Shock may respond to the administration of
blood. It may require the administration of extra-
cellular-like fluid in certain patients. It may re-
quire the elimination of abnormal vasomotion and
the substitution of appropriate vasopressor ther-
apy. It may respond to vasopressors alone, or to
adrenolytic agents alone. Treatment may be un-
successful in an occasional patient unless massive
doses of cortisone are given along with specific
antibiotics, plasma and other agents. Just as shock
may be complex, so also must treatment occasion-
ally be complex.

The treatment of resistant shock remains one of
the greatest challenges to the art of medicine. That
challenge must be accepted. We have the means.
We have now a great deal of information derived
from experimentation with animals. The patient
with resistant shock who fails to respond to what
are considered the standard, conventional forms
of treatment, and who appears on the road to in-
evitable death if those forms of treatment are con-
tinued is in need of immediate, cautious trial of
newer forms of treatment which may seem indi-
cated, even though extensive reports of carefully
controlled series of patients are not yet available
in the literature. Blind persistence in the adminis-
tration of any agent is not indicated on the basis

The Lift in

The frequency with which a simple procedure
alleviates an aggravating symptom is known to all
of us. In one area, particularly, that of low back
pain, the trial of a simple shoe lift is often over-
looked. When this is recommended by an irregu-
lar practitioner, its success is a source of embar-
rassment to the qualified practitioner.

Perhaps we do not use shoe lifts as much as we
should because of the element of quackery which
has grown up about it. Often enough, cases of back
pain and even frank disk protrusions are helped by
heel elevations on the asymptomatic side which
divert the superincumbent weight, taking pressure
off the constricted nerve root.

Certain conditions about the legs and feet are
very definitely helped. These include such things
as tenosynovitis or irritation of the bursa in the
region of attachment of the tendo achillis. It is
also helpful in relief of symptoms following par-
tial ruptures of gastrocnemius or soleus muscles,
or entire rupture of the plantaris tendon. A heel

that it is a standard form of treatment, if the pa-
tient has failed to show an acceptable response.

The objectives in the use of agonists and antag-
onists are summarized in Figure 4, and the point
is emphasized that blood volume expansion is
closely linked to therapeutic alteration of existing
abnormal vasomotion. The purpose is to increase
vascular tone enough to improve venous return,
but this must not lead to ischemic damage of the
kidneys or other vital organs. When there is evi-
dence of excessive vasospasm, then antagonists of
norepinephrine are required, plus blood volume
expansion. The worst use of agents results when
agonists are given to severely vasoconstricted pa-
tients. Likewise, the administration of adrenolytic
agents to patients in severe peripheral vascular
collapse should be avoided.

When the patient has a return of normal skin
color and his skin is warm and dry, when there is
a prompt return of color to nail beds and fingers
after compression, when the patient is alert and no
longer complaining of thirst or showing signs of
air hunger, and finally, when urine is flowing at a
rate of six or seven drops a minute, then and only
then can the physician be satisfied with a “normal”
pulse and a “normal” blood pressure.

Tissue perfusion is the objective in the treat-
ment of shock.

the Shoe

lift in such a situation will taken tension off the
tendon and provide definite relief.

A shoe lift is far from a panacea and is all too
frequently disappointing. Despite careful theoretic
reasoning, many cases are not helped by the lift.
On the other hand, it seems certain that many
favorable responses are more than psychologically
induced.

We are less empirically minded than we used
to be — we must know exactly why a thing works
before we use it. This is scientifically commend-
able. The impatience of the lay person is under-
standable. He wants relief and quick relief. If a
simple procedure will do this while we study the
problem, well and good.

The patient need not drift from his doctor’s office
to that of the unlawful practitioner if we focus
on the obvious as well as the obscure.

— Editorial, new york state journal
of medicine, 62:780, (Mar. 15) 1962

Listeriosis in the Newborn

IRVIN S. SNYDER, Ph.D., and
HERBERT P. MILLER, JR., M.D.
Iowa City

Until recently, Listeria monocytogenes has been
isolated infrequently from human beings. From
1949 to 1954, just 22 cultures of Listeria monocyto-
genes were submitted to the U.S.P.H.S. Communi-
cable Disease Center in Chamblee, Georgia, but
68 cultures were submitted in the following three
years.9 Until 1949, just 70 cases of listeriosis were
reported in the literature,1 but between 1950 and
1955, there were reports of 200 cases.15 Additional-
ly, between 1955 and 1957, a total of 150 publica-
tions on listeriosis appeared.16 The increased fre-
quency with which bacteriologists and physicians
have recognized the organism and the diseases that
it causes has resulted from their greater familiar-
ity with it.

The purpose of this report is to transmit our
experience in the isolation and identification of
this organism, and to describe the clinical and
pathologic aspects of one infectious disease process
attributed to it, as observed recently at the State
University of Iowa Hospitals.

CASE REPORT

A full-term female infant (Autopsy No. A-60-
431) was born September 21, 1960, following an
uneventful pregnancy. Her birth weight was 7 lbs.
6 oz., and she was her mother’s fifth child, the
four preceding pregnancies having been complete-
ly normal. There was no other significant family
history. Shortly after birth, the infant developed a
slight cyanosis, and mucus was suctioned from the
throat. The child gradually became more cyanotic
and lethargic, however, and was transferred to
University Hospitals, Iowa City.

On admission, the child was having generalized
convulsions, was cyanotic and did not respond to
stimuli. Numerous small pink spots were noted,
primarily over the trunk. The temperature was
99.4° F., the pulse was 160 per minute, and the
respirations were 55 per minute. A few rales were
heard in both lungs. The liver felt enlarged, and
the spleen was just palpable. The deep tendon re-

Dr. Snyder is an associate in the Department of Bacteriol-
ogy, and Dr. Miller is a resident in the Department of Pathol-
ogy. at the S.U.I. College of Medicine.

flexes were depressed. The remainder of the physi-
cal examination was not remarkable.

The hemoglobin was 16.7 Gm./lOO ml., and the
white blood cell count was 14,650/cu. mm., with
28 per cent segmented polymorphonuclear leuko-
cytes, 41 per cent bands, 13 per cent lymphocytes,
10 per cent monocytes, 1 per cent eosinophils, 4
per cent myelocytes, and 3 per cent metamyelo-
cytes. X-ray examination revealed multiple ill-
defined densities scattered throughout both lung
fields, and a normal heart. A lumbar puncture
showed only five white blood cells per cubic milli-
meter. Nose and throat cultures, blood and spinal

Figure I. Focal area of necrosis and cellular reaction in the
cortex of the adrenal gland. Hematoxylin and eosin. XI00.

192

Vol. LII, No. 4

Journal of Iowa Medical Society

193

fluid were submitted for bacteriologic examination.

The clinical impression was septicemia, and oxy-
gen, intravenous fluids, and intravenous penicillin
and chloramphenicol were administered. Dilantin
was also given for the convulsions. Despite these
measures, the infant’s condition deteriorated, her
cyanosis deepened, and her rales became coarse.
Fine tremors and occasional jerking persisted, and
terminally the respirations were quite labored.
The child died on the morning of September 23,
approximately 32 hours after birth.

An autopsy was performed seven hours after
- death. The body measured 50.5 cm. from crown
to heel, and weighed 3,180 Gm. Significant findings
on gross examination were limited to the lungs,

I spleen and liver. The right lung was slightly in-
creased in weight, at 39 Gm. The pleural surface
was dark red, smooth, firm, and noncrepitant. The
cut surface was dark red and congested. Moderate
inflammation of the bronchial mucosa was ob-
served, with considerable amounts of dark brown,
tenacious mucoid material in the lumina. The left
lung weighed 32 Gm. The pleural surface was
light pink and smooth, with a fleshy consistency
and some crepitation. The cut surface showed
moderate congestion and small amounts of brown

Figure 2. Cellular reaction within the lesion shown in
Figure I . X 600.

mucoid material in the bronchi. The vessels of
both lungs were normal. The spleen and liver
were moderately congested and slightly increased
in weight, but showed no other gross abnormality.

Significant findings on microscopic examination
were present in the lungs, heart, liver, adrenals
and lymph nodes. The lungs showed extensive
areas of collapse and pneumonitis. Alveoli and
bronchioles contained inflammatory and hemor-
rhagic exudate. Inflammatory cells consisted of
polymorphonuclear leukocytes and monocytes.
Clumps of gram positive cocci and gram positive
rods were observed in the bronchioles. One focal
area of necrosis was identified in the lung tissue
near the pleural surface. A few gram positive
rods were discerned within that area. The most
striking findings were seen in the adrenals and
lymph nodes. Areas of necrosis were scattered
throughout the cortices and medullae of the
adrenal glands (Figure 1). Histiocytes, polymor-
phonuclear leukocytes and cellular debris occurred
in those foci (Figure 2). Similar well developed
necrotic foci were seen in the lymph nodes, usually
in a subcapsular position. A single but well de-
veloped focus was identified in the myocardium.
The liver contained an occasional small area of
early necrosis, and also showed rather extensive
extramedullary hematopoiesis. Gram positive rods
were identified in all areas of necrosis except those
in the liver. They were frequently numerous in
the centers, and often appeared slightly beaded,
curved or club-shaped (Figure 3). An occasional
gram negative rod was seen in those areas too.

BACTERIOLOGY

The specimens submitted to the Bacteriology
Diagnostic Laboratory were blood, spinal fluid,
and nose and throat cultures ante mortem, and
blood, lung tissue and splenic tissue post mortem.
The nose and throat swabs showed Escherichia
coli, along with normal flora. Escherichia coli grew
out of splenic tissue, and Escherichia coli, hemo-
lytic Staphylococcus aureus and Pseudomonas

TABLE I

BIOCHEMICAL PROPERTIES OF
LISTERIA MONOCYTOGENES

glucose

acid

inositol

maltose

acid

galactose

xylose

glycerol

rhamnose

inulin

salicin

acid

methyl red

. . . +

dextrin

acid

Voges-Proskauer

. . . +

arabinose

citrate

lactose

H S

sucrose .

urea

—

mannitol . . . .

. , -

motility

. . . +

194

Journal of Iowa Medical Society

April, 1962

aeruginosa grew from the lung tissue. No growth
was obtained from the postmortem blood, but a
gram positive rod that appeared to be a diph-
theroid was isolated from the blood and cerebro-
spinal fluid that had been obtained on the day of
death. The organism was subsequently identified
as Listeria monocytogenes type 4b. Figure 4 shows
the appearance of these gram positive rods in pali-
sade arrangements. On 5 per cent sheep blood
agar, incubated at 37° C. for 24 hours, tiny pin-
point colonies were observed, and after 48 hours
they had enlarged to approximately 1 mm. in di-
ameter and were surrounded by small zones of
beta hemolysis. Figure 5 demonstrates the colonial
morphology. The small zones of beta hemolysis can
be observed in Figure 6. The biochemical proper-
ties of this organism, grown at 37° C., are shown
in Table 1. The organism was motile at both 37°
and at 25° C.

Inoculation of a heavy suspension of the isolated
strain of Listeria monocytogenes intraperitoneally
caused white mice to die within 48 hours. The
spleens and livers of the mice contained numerous
minute necrotic foci. One of the features of the
disease in mice is an acute conjunctivitis. Inocula-
tion of the eye of a rabbit by swabbing produced a
purulent conjunctivitis that progressed to corneal

Figure 3. Gram positive rods in phagocytes noted within a
local lesion in the adrenal gland. Gram stain. XI200.

opacification. The reactions observed in the rab-
bit’s eye are shown in Figure 7.

As a result of these tests, the organism was iden-
tified as Listeria monocytogenes, and the identifi-
cation was confirmed by Mr. Edward Byers, bac-
teriologist at the State Hygienic Laboratory in
Iowa City, and by the U.S.P.H.S. Communicable
Disease Center in Chamblee, Georgia.

Antibiotic sensitivity tests utilizing commercially
available discs revealed that growth of this strain
of Listeria monocytogenes was inhibited by low
concentrations of novobiocin, erythromycin, tetra-

«•

$>4|r

<y 1 \ *

* #t

Figure 4. Gram stain of L. monocytogenes showing palisade
arrangements.

Figure 5. Colonies of L. monocytogenes on surface of blood
agar plate.

Vol. LII, No. 4

Journal of Iowa Medical Society

195

cycline, chloramphenicol, penicillin, streptomy-
cin, bacitracin, neomycin, vancomycin, sulfadi-
azine, sulfamethoxypyridazine (Kynex), sulfadi-
methoxine, sulfasoxazole (Gantrisin) and sulfa-
ethylthiadiazole, and by a combination of sulfadi-
azine, sulfamethazine and sulfamerazine (Triple
Sulfa).

Uterine and cervical swabs from the infant’s
mother were obtained after her discharge from the
hospital. Listeria monocytogenes could not be iso-
lated from those specimens. Only one serum speci-
men was obtained from the mother. Using a live
suspension of the organism isolated from the in-
fant, an agglutination titer of 1:160 was obtained.

Figure 6. Colonies of L. monocytogenes showing narrow
zones of beta hemolysis.

The significance of that titer remains unknown,
since a subsequent serum could not be obtained.

DISCUSSION

Several clinical forms of Listeria infection in
humans are well recognized and reported. Men-
ingitis in the newborn and in older, often de-
bilitated adults has been seen most commonly in the
United States. Granulomatous sepsis, also referred
to as granulomatosis infantiseptica, or miliary
granulomatosis, has constituted an important seg-
ment of the cases reported in the European litera-
ture, but less so in the United States. The less fre-
quent forms include a septic-typhoidal form, an
oculo-glandular form, a septic type with mono-
nucleosis, and rarely a subacute bacterial endo-
carditis. Several cutaneous cases have been re-
ported. Extensive reviews of the subject in the
English literature are those by Murray,11 Hoe-
prich6 and Seeliger.16 Our case is one of granulom-
atous sepsis of the newborn.

The means by which the fetus becomes infected
is uncertain, but the process may occur in utero
or during delivery from organisms harbored in the
mother’s vagina. Infection, in utero by a trans-
placental route, is probably the usual occurrence.
Microscopic and cultural examinations of placental
and cord tissues in such cases have revealed large
numbers of the organisms.12 In other instances,
primarily spread to the fetus by aspiration of in-
fected amniotic fluid may occur. This is suggested
when the lesions in the fetus are confined prima-
rily to the respiratory and gastrointestinal tracts.
But the mode by which the infection passes the in-
tact membranes is not clearly established. When
infection in the fetus first becomes manifest a week
or two after delivery, the organism is more likely
to have been acquired during passage through the
vagina.

Figure 7. Figure on the left shows purulent conjunctivitis two days after ocular instillation of L. monocytogenes. The figure on the
right shows corneal opacification 12 days after ocular instillation of L. monocytogenes.

196

Journal of Iowa Medical Society

April, 1962

Listeriosis in the perinatal period and during
pregnancy is perhaps most characteristically seen
with little or no manifestation in the mother, but
with severe or fatal disease in the infant. The
mother may have a few mild and non-specific
symptoms and signs, such as those of a cold or
diarrhea. Significant fever may be present. Rarely,
more severe disease, such as pyelitis of pregnancy
and meningitis, has been reported.

Manifestations in the fetus probably depend
considerably on how long the infection has been
present prior to delivery, and on its severity.
Premature delivery and stillbirth may occur. If
living, the infant may be gravely ill at birth, and
may live for only a short time. But signs are fre-
quently delayed for from 24 to 48 hours, after
which there is a rapid deterioration. Then granu-
lomatous sepsis will usually be present, with or
without meningitis. As we have said, if infection
occurs during delivery, signs may not develop for
a week or more. In such cases septicemia occurs,
but the central nervous system is likely to be pre-
dominantly affected with a meningitis. Signs that
develop in the newborn are not characteristic of
any specific infection. Respiratory signs of increas-
ing severity are most usually reported, with cy-
anosis and apnea, refusal of feedings, diarrhea,
fever, muscular twitchings and convulsions. Oc-
casionally, an erythematous rash may be seen.
Pink areas on the skin were noted clinically in
the case that we have just reported, but they were
not observed post mortem.

The lesions of listeriosis in the newborn are
fairly characteristic. Scattered foci of necrosis are
found in a few or many organs. Macroscopically,
these are seen as pinhead-sized, grayish foci in the
tissue, although in early lesions no macroscopic
findings may be evident. If central nervous system
infection has developed, a purulent type of men-
ingitis will usually be seen. A bronchopneumonia
with foci of necrosis in the lungs is frequently
present. Microscopically, there is initially a necrot-
ic focus about which a predominantly granu-
lomatous reaction develops, with a variable num-
ber of polymorphonuclear leukocytes. Gram stains
will usually reveal gram positive rods in the
center and in phagocytic cells. The tissues com-
monly involved include the adrenals, liver, spleen,
lungs, pharynx, gastrointestinal tract, central
nervous system and skin. The heart, kidneys and
other tissues may also show lesions and organisms.
If there is an opportunity to examine the placenta
and umbilical cord, extensive inflammatory cell
infiltration and numerous gram positive rods may
be seen. Histiocytes, lymphocytes and plasma cells
are usually most numerous beneath the chorionic
membrane and in the intervillous spaces. In addi-
tion to the diffuse inflammation, focal lesions may
also be seen. In the umbilical cord, the cellular
infiltrates are seen around the vessels.

Because the infections that Listeria mono-
cytogenes can produce are myriad, a bacteriologic

identification is essential in the diagnosis of listeri-
osis. However, there are several problems that
face the bacteriologist. The first of them is the
differentiation of Listeria monocytogenes from the
Corynebacterium species or diphtheroids which
appear in many clinical specimens either as con-
taminants or as “normal flora.” Differentiation be-
tween Listeria monocytogenes and Erysipelothrix
rhusiopathiae must also be accomplished. The bio-
chemical activities of Listeria may be of some val-
ue, but they are not consistent enough to be
relied upon. In general, L. monocytogenes fer-
ments glucose, maltose, rhamnose, salicin and dex-
trin, producing acid without gas. The production
of beta hemolysis may be of some value, but it
must be remembered that occasional strains of
Erysipelothrix rhusiopathiae and some strains of
Corynebacteria are also hemolytic. In addition,
the zone of hemolysis may be small and may not
appear for two or three days. Listeria mono-
cytogenes is motile at both 37° and 25° C., but
because it is sluggish at the former of those tem-
peratures, motility studies should be performed
at both of them. Erysipelothrix rhusiopathiae is
non-motile, and of the Corynebacterium species,
only the following plant pathogens are motile:
C. poinsettiae, C. hypertrophicans, C. trituci and
C. flaccumfaciens.2

Listeria monocytogenes can best be identified
by its animal pathogenicity. Porter and Hale13
have shown that mice inoculated with Listeria
monocytogenes die in periods ranging from 48 to
72 hours, whereas those infected with Erysipelo-
thrix rhusiopathiae die later. The outstanding
feature in these animals is a marked focal necrosis
of the liver. Morris and Julianelle10 demonstrated
the production of a kerato-conjunctivitis followed
by corneal opacification in a rabbit’s eye swabbed
with cultures of Listeria monocytogenes. Some
strains of Erysipelothrix rhusiopathiae produce
this reaction, one that eventually is fatal to the
animals.8

Thus, on the basis of fermentation reactions,
hemolysis, motility and animal pathogenicity, the
average bacteriologic laboratory can identify Lis-
teria monocytogenes. However, the isolation of
the organism from tissue and exudate may be diffi-
cult. Gray et al.5 have shown that bovine brain tis-
sue negative for growth of Listeria on primary cul-
ture yielded numerous organisms when homog-
enized brain tissue was incubated at refrigera-
tion temperature and subcultured at intervals
over a period of five weeks to three months. This
luxuriant growth on subculture may be explained
on the basis that L. monocytogenes will grow at
refrigeration temperature, whereas most bacteria
will not. This characteristic enables the Listeria
to attain the numbers that are necessary for sub-
culture. Additionally, it has been suggested that
tissue contains substances inhibitory to the growth
of Listeria, and that the breakdown of the material
permits growth. Other organisms may have some

Vol. LII, No. 4

Journal of Iowa Medical Society

197

inhibitory effect. Several selective media have
been devised to overcome that problem.10 Recogni-
tion of colonies of L. monocytogenes can be facili-
tated through the use of oblique illumination.1

Our failure to isolate the organism from post-
mortem tissues in the case reported here was per-
haps due to this inhibitory effect of the other bac-
teria that were present, or to our failure to handle
the specimens in the manner described by Gray
et al.5

Serologic procedures are of little value in iden-
tifying L. monocytogenes at the average bacteri-
ologic laboratory. The presence of more than one
immunologic type of organism necessitates the
use of several specific antisera. These antisera
are not available commercially, and thus must be
prepared by the laboratory. Persons infected with
L. monocytogenes demonstrate the formation of
agglutinins and complement-fixing antibodies. Be-
cause of the frequent appearance of Listeria ag-
glutinins and complement-fixing antibodies in the
sei'ums of healthy individuals, it is necessary that
either an increase or a decrease in titer be demon-
strated. Additionally, cross-reactivity of Listeria
antiserum with enterococcal and staphylococcal
antigens requires absorption of the serum to re-
move these cross-reacting antigens.16 Although
the titer of antibody to L. monocytogenes has been
shown to increase after infection, no correlation
has been shown between antibody level and im-
munity.16

The type of specimen submitted for bacteri-
ologic examination in neonatal listeriosis is im-
portant. Early in the disease, bacteria are present
in the blood stream, and the ideal specimen can
be obtained at that time. Later in the disease
process, the intracellular nature of the organism
and its affinity for the reticuloendothelial system
make a bacteriologic diagnosis more difficult. How-
ever, the organism can be isolated from bone mar-
row. Umbilical blood, spinal fluid and placenta
should be examined bacteriologically. The finding
of gram positive rods in meconium, which nor-
mally either is sterile or contains very few or-
ganisms, may suggest the possibility of neonatal
listeriosis and is essential for the early diagnosis
of the disease.16

Where do infections with L. monocytogenes
originate? The organism has been found to cause
disease in 27 species of animals, among them being
sheep, cattle, swine and chickens.14 In cattle, sheep
and goats, an infection results in a disease of the
central nervous system and produces abortions.
Abortions likewise are produced in swine, but in
chickens the result is a septicemia and myocardial
degeneration with necrosis. The presence of large
numbers of these animals in Iowa makes this dis-
ease a greater threat here than in many other
places, since it is transmissible from animal to
man. Physicians and bacteriologists in Iowa must
become aware of this problem.

The danger that pregnant women may come into

contact with diseased animals and the danger
of drinking unpasteurized milk need to be empha-
sized. Emphasis also must be given to the danger
of transmission of listeriosis to physicians and
attendants of a case of neonatal listeriosis.16

As can be seen from the foregoing discussion,
the clinical features of listeriosis of the newborn
are not so well defined that a case can be diag-
nosed on that basis. In fact, the disease is rarely
suspected on the basis of clinical evidence. Specific
diagnosis rests with the alertness of the bacteri-
ologist and pathologist, and depends upon their ob-
taining suitable specimens. The initial isolation of
the organism in a given institution or area is fre-
quently followed by the recognition of additional
cases. At postmortem examination, the macro-
scopic findings may not give a clue as to the cause
of death. Although the histologic changes are
sufficiently characteristic to suggest the disease,
particularly if the organisms can be seen, their
significance may be overlooked, as occurred in the
initial examination of the microscopic sections in
our case. In addition to routine cultures that may
be obtained at postmortem, cultures should be
made of the liver, brain, lymph nodes, lungs,
adrenals or other tissues that are predominantly
affected by this disease.

The true incidence of listeriosis of the newborn,
like the incidences of the other forms of the dis-
ease, cannot easily be determined, but writers on
the subject almost universally agree that the rate
is higher than is generally realized. One series re-
ported from Germany showed that approximately
3 per cent of perinatal deaths in 3,246 deliveries
had been due to proved Listeria infection.3 Syste-
matic studies in this country suggest a similar or
lower mortality. Welshimer and Winglewish17 ex-
amined the meconiums of over 170 aborted fetuses
and infants who had died shortly after birth, and
failed to recover L. monocytogenes in any instance.
Hood7 examined 66 cases of threatened or actual
abortion, or of postpartal sepsis, and recovered
the organism in pure culture from the reproduc-
tive tract of the mother and from her aborted fetus
in only one instance.

Listeriosis probably has a higher mortality
among newborn patients than among patients in
other age groups. The death rate is above 95 per
cent in the infant cases that have been reported
from outside the United States.16 In the largest
series of cases reported from the United States,
the mortality was 83 per cent in infants ill from
birth, but those who had become ill between one
week and one month after birth had a mortality
of 33 per cent.7 Probably the poor prognosis for
those ill at birth is due to the presence of already
well advanced and disseminated infection. In the
infants who became ill after a week or so, the
disease may have been recognized at an early
stage when it was amenable to adequate therapy.
The predominant clinical manifestations in such
cases suggested meningitis, and the organism could

198

Journal of Iowa Medical Society

April, 1962

almost always be cultivated from the spinal fluid.
Although some of the patients undoubtedly would
survive without treatment, the mortality in un-
treated cases is estimated at between 70 and 80
per cent.4

Early and adequate chemotherapeutic and anti-
biotic treatment is capable of reducing the mor-
tality in listeriosis. The greatest success, according
to the reports, has come from the use of multiple
agents. Sulfonamides, penicillin, streptomycin,
chloramphenicol, the tetracyclines and erythromy-
cin have been utilized in combinations of two or
three. Consequently, it has been difficult to eval-
uate the effects of any single drug in individual
cases. Seeliger16 recommends the tetracyclines as
the drugs of choice. Erythromycin is also effective.
Hoeprich16 recommends penicillin as the agent of
choice because of the bactericidal levels that are
clinically attainable, and suggests using erythro-
mycin in combination with it. However, the rec-
ommendations in regard to penicillin are conflict-
ing. Seeliger says it is of little value when used
alone, although moderately efficient in combina-
tion with streptomycin or the sulfonamides. Hood7
does not recommend penicillin, and reports finding
eight of 10 strains of the organism isolated from
patients to be resistant to it in vitro. Streptomy-
cin alone is not recommended because of the rapid
development of resistance. Chloramphenicol has
been recommended because of its easy passage
through the blood-spinal fluid barrier. It thus ap-
pears that a combination of drugs in full dosage
for 10 days or more offers the best treatment.

Although the occurrence of listeriosis of the
newborn may be relatively rare, the serious prog-
nosis warrants an awareness and a careful study
of the problem. Effective measures for its preven-
tion must await further clarification of the epi-
demiology. A more immediate approach to its con-
trol is aptly indicated in Hood’s report of several
cases.7 Listeric septicemia was recognized on the
basis of blood culture in women suffering from
fever and malaise during the last trimester of
pregnancy. All responded to therapy and delivered
healthy infants, although one of them was pre-
mature. In the cervix of the woman who delivered
her baby prematurely, Listeria was the predom-
inant organism. The infant was observed carefully
for signs of infection, and on the eighth day de-
veloped signs of meningitis. L. monocytogenes was
isolated from the spinal fluid and blood. Intensive
antibiotic therapy was instituted, and the mother
and child eventually were discharged as well. It
appears that relatively slight and harmless infec-
tions should not be disregarded during pregnancy.
Treatment of the infant at the earliest signs of in-
fection is recommended, and the therapy should
subsequently be adjusted as cultures and sensi-
tivity tests indicate.

SUMMARy

The clinical, pathologic and bacteriologic aspects
of a case of neonatal listeriosis have been pre-

sented. The difficulty of diagnosing the disease
clinically has been emphasized, together with the
importance of making a bacteriologic diagnosis.

It is essential that both the physician and the
bacteriologist be familiar with the disease pro-
duced by the organism, and with the methods to
be employed in identifying it.

ACKNOWLEDGMENT

We should like to thank Dr. John D. Good, who
performed the autopsy, and the Department of
Pediatrics, which permitted us to report this case.

REFERENCES

1. Beams, R. E., and Girard, K. F.: On isolation of

Listeria monocytogenes from biological specimens. Am. J.
Med. Tech. 25:2:120-126, (Mar.-Apr.) 1959.

2. Breed, R. S., Murray, E. G. D., and Smith, N. R.: Ber-
gey’s Manual of Determinative Bacteriology, Seventh Edi-
tion. Baltimore, The Williams and Wilkins Co. 1957.

3. Breuning, M., and Fritzsche, F.: Uber die Haufigkeit der
Listeriose bei Neugeborenen. Geburtsh. u. Frauenh. 14:1113-
1124, (Dec.) 1954.

4. Delta, B. G., Scott, R. B., and Booker, C. R.: Listeria
meningitis in newborn. Med. Ann. District of Columbia 30:-
329-334, (June) 1961.

5. Gray, M. L., Stafseth, H. J., Thorp, F., Jr., Sholl, L. B.,
and Riley, W. F., Jr.: New technique for isolating listerel-
lae from bovine brain. J. Bact. 55:471-476, (Apr.) 1948.

6. Hoeprich, P. D.: Infection due to Listeria monocytogenes.
Medicine 37:143-160, (May) 1958.

7. Hood, M.: Listeriosis as infection of pregnancy mani-
fested in newborn. Pediatrics 27:390-396, (Mar.) 1961.

8. Julianelle, L. A.: Identification of erysipelothrix and
its relation to listerella. J. Bact. 42:385-394, (Sept.) 1941.

9. King, E. O., and Seeliger, H. P. R.: Serological types
of Listeria monocytogenes occurring in United States. J. Bact.
77:122-123, (Jan.) 1959.

10. Morris, M. C., and Julianelle, L. A.: Study of ocular
infection induced experimentally with Bacterium mono-
cytogenes. Amer. J. Ophth. 18:535-541, (June) 1935.

11. Murray, E. G. D. : Characterization of listeriosis in
man and other animals. Canad. M. A. J. 72:99-103, (Jan. 15)
1955.

12. Olding, L., and Philipson, L.: Two cases of listeriosis
in newborn, associated with placental infection. Acta path,
et microbiol. scandinav. 48:24-30, (Fasc. 1) 1960.

13. Porter, J. R., and Hale, W. M. : Effect of sulfanilamide
and sulfapyridine on experimental infections with Listerella
and Erysipelothrix in mice. Proc. Soc. Exper. Biol. & Med.
42:47-50, (Oct.) 1939.

14. Reed, R. W. : “Listeria and Erysipelothrix.” In: Dubos,
R. J.: Bacterial and Mycotic Infections of Man. 3rd Ed.,
Philadelphia, J. B. Lippincott, 1958, pp. 453-469.

15. Seeliger, H.: Listeriose IBeitrage zur Hygiene und Epi-
demiologie, Heft. 8] Leipzig, East Germany, Johann Ambrosius
Barth, Verlag, 1955.

16. Seeliger, H. P. R.: Listeriosis. New York, Hafner Pub-
lishing Co., 1961.

17. Welshimer, H. J., and Winglewish, N. G.: Listeriosis —
summary of seven cases of listeria meningitis. J.A.M.A.
171:1319-1323, (Nov. 7) 1959.

IMS Nominating Committee
Meeting

The Iowa Medical Society’s Nominating
Committee is to meet at the headquarters
office in Des Moines on Wednesday, April
18, at 1: 30 p.m. All members of the Society
will be given the names of the physicians
who compose the Nominating Committee
sometime within the first 10 days of April,
by direct mail.

Extracorporeal Dialysis

In Renal Failure

RICHARD E. HOCKMUTH, M.D.
LUKE C. FABER, M.D., and
EDWARD E, MASON, M.D.

Iowa City

This is to be a review of the experience at the
State University of Iowa Hospitals in the treat-
ment of patients by means of the artificial kidney.
It has been our objective to find out how this ad-
junct has been used, and to determine to what
extent its use has been either effective and worth-
while or ineffective and therefore wasteful of
valuable time and facilities. Physicians practicing
in Iowa should find such a review helpful in de-
ciding which patients to refer to centers where
artificial kidneys are available. In addition, a num-
ber of specific patients will be described, who
seem to illustrate certain points relative to diag-
nosis, prognosis and the development of an over-
all treatment plan.

There are patients who need early treatment in
a renal center. There are other patients in whom
some other problem may be immediately impor-
tant, even though transfer to a renal center will
ultimately be required. Some patients may be
cared for locally for a time, until renal failure
is definitely found to be present. The temptation,
then, may be to procrastinate regarding transfer
until urgent or emergency indications appear.
There are some patients who probably will not
be helped in more than a very temporary way
by the artificial kidney. The problem of diagnosis
and prognosis then becomes paramount, and often
the artificial kidney is required solely to provide
additional time for an attempt at a solution of
those problems by renal biopsy.

GENERAL OBSERVATIONS ON THE EXPERIENCE AT SUI

Ours is a rather modest series, and the extensive
reports from other institutions will therefore be
used to supplement our own experience in ar-
riving at any recommendations. The artificial kid-
ney was first established as a service at SUI just
two and one-half years ago. It has been maintained
by the Department of Surgery under the direc-

From the Department of Surgery at the SUI College of
Medicine.

tion of one of the members of the surgery staff.
Surgery residents are assigned to “extracorporeal
dialyses” as a part of their other rotations and
usually in addition to other assignments, since
running the artificial kidney has infrequently be-
come a full-time activity. The use of the artificial
kidney is scheduled as an elective procedure dur-
ing regular operating-room hours as often as is
compatible with good patient care. There are
many instances, however, when extracorporeal
dialysis must be an emergency procedure, but
this has become less common as the medical pro-
fession has become acquainted with the indica-
tions for dialysis. The procedure is now contem-
plated early, and is planned for as part of the
overall care of patients with acute renal failure.

Ninety dialyses have been administered to 39
patients. The experience is further categorized in
Table 1. It would appear from this table that the
greatest effort has been made in those patients
who derived the least benefit. In our effort to
extend possible benefits to patients who are bor-
derline candidates for such treatment, there is
often a question as to whether a patient should
be denied any treatment with the artificial kid-
ney, on the one hand, or whether perhaps earlier,
more frequent use of the artificial kidney might
be more effective in the final outcome, on the
other hand. In other institutions and early in the

TABLE I

USE OF EXTRACORPOREAL DIALYSIS
AT SUI HOSPITALS

No. of

Long Term

Average No.
No. of of Dialyses

Patients

Survival

Dialyses Per Patient

Nephritis

Renal Failure
and associated

0 patients

(0%)

disease

1 ntravascular

1 patient

(M%)

hemolysis TUR

1 patient

(25%)

1 1

Trauma

Poisoning and toxic

2 patients

(33%)

reactions ... 9

Postpartum hemorrhage
and transfusion

8 patients

(86%)

reaction

2 patients

(100%)

199

200

Journal of Iowa Medical Society

April, 1962

history of the artificial kidney, the poor results
were attributed to poor selection of patients and
to delays in using it in those patients who should
have responded to it.

At the present time, excellent results are usually
obtained in patients with acute renal failure due
to postpartum hemorrhage, transfusion reactions,
intravascular hemolysis and poisoning. The im-
mediate results may be excellent in patients with
chronic glomerular nephritis, but in our experience
when the disease has reached this stage, repeated
dialyses are required to maintain the improve-
ment, and the chief justification seems to be in
instances where the diagnosis has not been es-
tablished and where there is still some hope that
the renal failure actually is due to a reversible

process. There may be instances of acute glomeru-
lar nephritis of such severity as to cause a poten-
tially lethal uremia but without permanent, irre-
versible damage. This is only a hope at present. We
have not seen such a patient, but the artificial kid-
ney should be used in any patients in whom the
pathologist believes there is such a possibility, on
the basis of his examination of a kidney biopsy.

THE ARTIFICIAL KIDNEY IN CASES OF POISONING

Acute renal failure needs to be defined in a
very pragmatic way for those of us who either
must refer patients to renal centers or must treat
patients in those centers. Acute renal failure is a
temporarily inadequate renal function with a
danger of serious morbidity or death, and it may

Figure I demonstrates some of the observations made during treatment of a 68-year-old woman with hypertension, who had been
treated with thiocyanates for six weeks. A plot of serum thiocyanate is shown on the ordinate in mg. per cent. The days of observa-
tion are plotted on the abscissa. The rapid fall in serum thiocyanate on the first day was due to removal of thiocyanate by extra-
corporeal dialysis (ECD), which was carried on for a period of four hours. We are indebted to Dr. Robert Dryer, biochemist, for
frequent analyses of thiocyanate in blood, urine and dialysate. The slope of the serum thiocyanate curve and the figures for excre-
tion show that the artificial kidney was at least 100 times as efficient in removing thiocyanate as were the patient's own kidneys.
There was no evidence of any abnormality in kidney function. Thiocyanate is poorly excreted. It tends to be reabsorbed, much as
chloride is reabsorbed from the glomerular filtrate.

Vol. LII, No. 4

Journal of Iowa Medical Society

201

be a relative state which, in certain circumstances,
may exist without significant demonstrable renal
damage. There are certain poisonous substances
that are normally excreted by the kidney but so
slowly that the artificial kidney must be called
upon to do the job.

Figure 1 shows the relative efficiency of extra-
corporeal dialysis, with the twin-coil kidney, in the
removal of thiocyanate, as compared with the nor-
mal kidneys of a 68-year-old woman with essential
hypertension. She had been treated with thiocy-
anates for six weeks until she became disoriented,
psychotic and in need of hospitalization. The se-
rum thiocyanate level of 32 mg. per cent was in a
range that has been reported as lethal. A rapid
reduction of body thiocyanate was carried out
with the artificial kidney during a five-hour peri-
od. In the normal kidney, thiocyanate is filtered
through the glomerulus and then to a great ex-
tent is reabsorbed from the tubular lumen. When
blood containing this highly mobile, small-sized
molecule is passed through a cellophane mem-

brane, with a dialysate on the other side of the
membrane that contains no thiocyanate, the re-
moval occurs rapidly. Immediately after the dial-
ysis, the patient’s serum thiocyanate was 5 mg.
per cent. The level rose as thiocyanate moved into
the blood from other portions of the total body
pool. This early rebound is observed also for urea,
creatinine and other substances that are removed
by the artificial kidney. If there is delay in ob-
taining blood samples after dialysis, it may there-
fore appear that the substance in question is be-
ing poorly removed. In this instance, further treat-
ments were not required. Sometimes the rapid re-
bound of waste substances in the blood after dial-
ysis requires repeated dialyses at relatively short
intervals until the material has been eliminated
not only from the blood and extracellular fluid
but from less accessible areas as well.

REMOVAL OF PRODUCTS OF CELL BREAKDOWN

There are circumstances when there is a tem-
porary obstruction of the kidney or an inter-

K+(mg/L)

Fis ure 2 shows what happened to a 12-year-old boy with acute lymphatic leukemia. The white blood cell count (solid line) can
be measured by the scale on the left ordinate, and the serum potassium concentration (dotted line) can be measured by the scale
on the right ordinate. The fall in white blood cell count was coincident with the administration of thioguanisine in doses of 20 to 80
mg. per day, as indicated by the arrows. The extremely high serum potassium levels on the eighth day led to the intravenous
administration of glucose, insulin and calcium, and to the use of ion exchange resins by rectal infusion while the artificial kidney
was being prepared. The serum potassium was rapidly lowered by extracorporeal dialysis during the period shown by the vertical
bar. The electrocardiogram showed the expected return to normal with correction of body chemistries. There was a rise again
during subsequent days, but a rapid return of urine flow obviated the necessity for further dialysis.

202

Journal of Iowa Medical Society

April, 1962

ference with its function by products of cell break-
down, and with an accompanying rise in serum
potassium from that same cell breakdown. Emer-
gency dialysis may then be used primarily to re-
move potassium. There were two children in the
present series in whom, as a result of the treat-
ment of leukemia with thioguanisine, there was
a very rapid lysis of white blood cells. Severe
oliguria developed, probably as a result of tubular
blockade with uric acid. Shortly after dialysis,
the kidneys resumed function, and both children
were discharged from the hospital in at least a
temporary state of remission and comfort. Figure
2 shows the white blood cell count and the serum
potassium level during the critical period for one
of those patients, a boy aged 12 with acute
lymphatic leukemia. The serum potassium level
was above 9 mEq./L. immediately prior to dialysis.

Other measures were used in an attempt to
prevent death from potassium poisoning while
preparations were being made for extracorporeal
dialysis. Glucose, insulin and calcium were given
intravenously and exchange resins were given by
enema, with only a temporary effect on the serum
potassium. The electrocardiogram was almost un-
recognizable, and there was a momentary cessa-
tion of heart activity just prior to the dialysis. A
slap on the chest was followed by resumption of
heart activity. Within 10 minutes after dialysis
was initiated, the electrocardiogram was restored
to a recognizable complex, although it still was
not normal. Potassium, like thiocyanate, is a very
mobile molecule, and has a high dialysance — i.e.,
rate of removal by the artificial kidney.

EXTRACORPOREAL DIALYSIS IN CASES OF
CRUSHING INJURIES

The above patients serve to illustrate what the
artificial kidney can accomplish, but the underly-
ing problems in those cases were rather unusual.
Also, actual kidney cell damage probably was not
present in those patients.

There are several conditions in which a release
of muscle or red blood cell pigments leads to acute
renal failure. Although these are conveniently
classified as pigment nephropathies, the precise
role played by the pigments, hemoglobin or myo-
globin, is not definitely understood. The best evi-
dence indicates that circulating pigments produce
profound renal vasoconstriction and initiate an
ischemuric episode. Added factors of dehydration,
hypovolemia, reflex vasospasm, sludging and re-
lease of endogenous norepinephrine potentiate the
ischemia and result in cortical or tubular necrosis.

Once this sequence of events begins, it is proble-
matical whether it can be interrupted or reversed.
The renal ischemia is often so rapid or unexpected
that appropriate treatment is not used when it
might be of benefit. It is of great advantage, there-
fore, to be aware of the possible sequelae in ad-
vance. Figure 3 presents the data on a 22-yeai’-old
man who had been pinned under an 800-pound

snow scoop for two and one-half hours, without
apparent severe injury. Fortunately, one of the
consulting physicians was familiar with the natural
history of crush injuries and made arrangements
by telephone for rapid transfer of the patient, in
case oliguria should develop. Within 12 hours, the
patient was undergoing dialysis for hyperpotas-
semia. In 12 hours the urinary output was 15 ml.,
and the potassium had risen from 5.6 to 8.1 mEq./-
L. A few hours’ delay would probably have been
fatal, since cardiac arrhythmia was noted just
before the dialysis started. Four other dialyses
were carried out, primarily for the removal of
potassium, and two for the removal of nitrogenous
waste products. Diuresis ensued 14 days after the
injury, and the patient made an uneventful recov-
ery.

EXTRACORPOREAL DIALYSIS SHOULDN'T ALWAYS
BE DONE FIRST

The diagnosis in the case just described was
made in time, as a consequence of the physician’s
awareness of the hazards that crushing injuries
pose. Most diagnoses of renal failure are made
only when oliguria, azotemia or uremia has ap-
peared, but it has been written that these criteria
are insufficient, since renal failure can occur with-
out a diminution of urinary volume. The composi-
tion of the urine is also an important guide to
the diagnosis of acute renal failure. It tends to
resemble plasma in that normal tubular sodium
reabsorption does not occur. Urinary sodium may
rise to 90 mEq./L. Urea is not actively excreted,
and thus its concentration is low. Specific gravity
remains low even with low volumes, since the
solutes are not concentrated. The presence or
absence of casts is not diagnostic, but the finding
of pigmented or granular casts without other ex-
planation is suggestive.

Once the diagnosis has been made, only one
thing precludes the institution of a fairly standard
plan of management, and that is the patient’s im-
mediate condition. Attention to the patient’s un-
derlying illness may indicate certain emergent or
urgent measures to be performed before he is
referred to a kidney center. Figure 4 lists the data
from a 19-year-old college student who had at-
tempted suicide by ingesting 40 Gm. of potassium
chlorate in divided doses. He was admitted to an
emergency clinic with marked cyanosis and ir-
regular respiration, though not in shock. Oliguria
was present. It was learned that, as a powerful
oxidizing agent, potassium chlorate could produce
severe methemoglobinemia, accounting for the
cyanosis. Two exchange transfusions of five liters
each were carried out on successive days, and his
condition improved. By that time, the serum
potassium and urea had become moderately ele-
vated, and so the patient was then transported to
our kidney center. He underwent four dialyses,
and then diuresis occurred and he made a com-
plete recovery. The exchange transfusions were

Vol. LII, No. 4

Journal of Iowa Medical Society

203

lifesaving, and the artificial kidney would have
been of little use at the early stage of the illness
when they were performed.

When special or immediate problems have been
resolved, the standard general plan of treatment
may proceed. It has been outlined many times
in the literature, and need not be detailed here.
However, the emphasis is on (1) restricting food
and fluid so that the patient loses weight; (2)
avoiding potassium and protein while providing
a minimum intake of 800 calories; and (3) pro-
tecting the patient from pneumonia and other in-
fections. Urinary-tract infection can be minimized
by not using indwelling catheters.

In the patients discussed thus far, some atten-
tion has been directed to the rate of progress of
the uremia and hyperkalemia that are manifesta-
tions of the patients’ general catabolic state. We
have not relied on exchange resins or on the ad-
ministration of testosterone to reduce the rate of
catabolism and the accumulation of potassium,
but rather we have tried to estimate the time when
treatment with the artificial kidney might be need-
ed and to institute such therapy as soon as possible

after the serum potassium began to approach 7
mEq./L.

WATER BALANCE

The rate of accumulation of urea, creatinine,
phosphorus and other waste products allows a
timely estimate of when dialysis will be required.
There is another extremely important factor in
these patients that frequently causes death and
therefore demands vigorous control, at times re-
quiring use of the artificial kidney. It is water
balance.

Pulmonary edema in uremia is due to overhy-
dration. The most striking illustration of this
problem in the present series was a 38-year-old
woman who was admitted to her hospital with
confusion and vomiting. She was treated there for
a number of days before it was observed that
she was not urinating normally. Finally, it was
learned that prior to her illness she had used car-
bon tetrachloride to clean floors in a closed room.
By the time the patient was seen at the SUI Hos-
pitals, her total body weight had risen to 132.5
lbs., as compared to her normal weight of 125 lbs.
She had been ill and unable to eat for one week,

Figure 3 shows data collected over a period of 50 days from a 22-year-old farm boy who had suffered a severe crushing injury of
the hips and lower extremities. The total body weight (open circles), serum potassium (dots) and serum creatinine (triangles) are
plotted as line graphs and the daily urine volumes as a bar graph, with the extracorporeal dialyses (ECO) shown by the high
vertical bars. There were seven treatments with the artificial kidney. Initially, these were at intervals of less than 24 hours. After the
large amounts of potassium and other waste products had been released from crushed muscle and eliminated by the artificial kid-
ney, the treatments were spaced at intervals of three or four days. Potassium-removing exchange resins were given by mouth, but
they did not eliminate the necessity for removing other wastes by dialysis. Diuresis began (i.e., exceeded 1,000 ml./day) on the
eighteenth day, and lasted about 18 days. This patient's daily urine concentration of glutamic oxaloacetic transaminase, leucine
amino-peptidase and beta-glucuronidase were reported in a recently published paper.

204

Journal of Iowa Medical Society

April, 1962

and thus she should have lost 7 lbs. An adult who
isn’t eating should lose a pound a day, on the
average, and if there is no weight loss, one can
take for granted that the fat and body tissue which
has been metabolized has been replaced by an
equal retention of water. It could thus be estimated
that this patient was about 14 or 15 lbs. overhy-
drated. If there had been no administration of salt,
then that increase in total body water should have
been accompanied by a dilution of electrolyte con-
centration of the same magnitude. As one can see
from Figure 5, the initial concentration of serum
sodium was 117 mEq./L., or almost exactly what
one would have predicted from this degree of
overhydration.

In other words, the total body water was 18 per
cent above normal, and the serum sodium was

decreased 18 per cent below normal. This inverse
relationship between total body water and serum
sodium concentration has been discussed before
in this journal and elsewhere, and is a useful
clinical check. The patient was severely dyspneic
and cyanotic. She was taken immediately to the
artificial kidney room, where with the patient in
a sitting position, positive pressure endotracheal
breathing was provided her for some eight hours,
while the artificial kidney was run for the purpose
of ultrafiltration. Four liters of excess fluid were
removed. Initially, the dialysate used was pre-
pared as a hypotonic solution so that a rapid shift
of water would not occur from the patient’s cells
to her extracellular fluid, further aggravating the
pulmonary edema. Even after that initial dialysis,
the patient was allowed to remain slightly hy-

Figure 4 shows some of the observations made after a 19-year-old male college student ingested 40 Gm. of potassium chlorate.
Initial treatment for methemoglobinemia consisted of two 5 L. exchange transfusions carried out in a nearby hospital. The patient
was not moved to the SUI Hospitals until the third day. Early transfer might have been dangerous because of the anoxic anoxia.
Four treatments with the artificial kidney are indicated by the high bars (ECD). Total body weight (open circles) , serum potassium
(dots) and serum creatinine (triangles) are shown as line graphs, and urine volume as a bar graph. This patient was allowed to eat
and drink a little more than was ideal for perfect water balance, in anticipation of the diuresis. The diuresis was excessive in part
for that reason, and some supplemental potassium was given him for several days, beginning on the seventeenth day. The theoret-
ical line for normal weight was calculated on the basis of the patient's previous normal weight minus one pound per day. The pa-
tient became hungry and was allowed some low-protein and low-potassium food and fluid beginning on the seventh day. These
were allowed in the knowledge that either he would soon diurese or that we would remove the excess fluid by ultrafiltration. Slight
overhydration is probably safe in otherwise healthy young patients, but is not recommended.

Vol. LII, No. 4

Journal of Iowa Medical Society

205

potonic and her body weight was still above that
calculated to be ideal for the number of days of
her starvation. It was only after the second dial-
ysis that her weight, sodium concentration and
pulmonary edema were completely corrected. The
subsequent return of kidney function and her
convalescence were uncomplicated.

When patients with acute renal failure are well
cared for, they do not succumb from the effects
of excess potassium or water, but some occasional-
ly fall prey to the ever-present bacterial popula-
tion. One young boy demonstrates this problem
strikingly, in that although we do not know the
cause of his renal failure, he had passed through

the diuretic phase and seemed certain to recover
when he developed a severe hemolytic Staphy-
lococcus aureus pneumonia and septicemia that
led to his death. This is a problem common to all
seriously ill patients, and the precautions and
treatment are the same here. The patient should
be protected from carriers of bacterial pathogens.
Prevention of pulmonary congestion again needs
to be mentioned in relation to the prevention of
pneumonia. Earlier and more frequent dialysis or
the prevention of the uremic state seems to im-
prove a patient’s resistance to infection. Prophy-
lactic antibiotics probably should not be used. One
specific caution — against the use of urinary cath-

Figure 5 shows the results ol some measurements in the case of a 39-year-old woman. The days following her exposure to carbon
tetrachloride have been plotted on the abscissa. Two high narrow bars on the eighth and twelfth days indicate the time of the
extracorporeal dialyses (ECD). The solid, heavy line joins the observed total body weights as compared with the narrower line
which shows the normal theoretical body weights for a woman normally weighing 125 lbs. and losing one pound per day. The inter-
rupted line joins open circles that indicate, on the right ordinate, the observed serum sodium concentrations. It is to be noted that
initially both a high body weight and a low serum sodium concentration indicated water overload. The patient's cyanosis, her poor
breath sounds and the chest roentgenogram showing generalized congestion were consistent with this. Excess fluid was removed by
ultrafiltration, and at the end of the second treatment (ECD) her weight was normal. The patient was then allowed to drink freely,
and became slightly overhydrated again until the diuresis became sufficient to bring her weight back toward normal. The daily urine
volumes are shown by the bar graph at the bottom of the figure, and the milliliters per day can be estimated from the ordinate on
the left.

206

Journal of Iowa Medical Society

April, 1962

eters — is often repeated. There is no advantage in
collecting a few milliliters of urine daily, and an
indwelling catheter greatly increases the likeli-
hood of serious urinary-tract infection, either dur-
ing or following recovery from acute renal failure.

USE OF THE ARTIFICIAL KIDNEY ISN'T ALWAYS
JUSTIFIABLE

The patients selected for presentation here dem-
onstrate the most important aspects of early eval-
uation, prediction relative to the rate of progres-
sion of uremia, plans for overall treatment, and
bases for decision as to when a patient should be
moved to a center for special care, if equipment
is unavailable in the immediate area. The subject
has been discussed by Lawton in this journal,*
and more specific details as to indications for the
actual timing of dialysis can be found in his
article. We agree with Lawton and others that
extracorporeal dialysis is not a dangerous pro-
cedure, that it should be used without fear, and
that it is better to use it early than too late. The
chief drawback to the artificial kidney is its
costliness in materials and in the time of highly
trained personnel. This is no problem where the
indications are clear. Many patients, in the prog-
ress of an ultimately fatal disease, become uremic,
and frequently the intensity of our desire to do
something for them leads us to consultations re-
garding extracorporeal dialysis. Many such pa-
tients have been seen, and in some an attempt has
been made to prolong life by removing water and
the waste products of metabolism and by restoring
normal body electrolyte composition. In a few
instances the effort seems to have been worth-
while. The two children with leukemia have been
mentioned. There were a few patients with chron-
ic glomerulonephritis whose lives were prolonged
for weeks or months in consequence of some very
expensive and persistent efforts. Perhaps the pa-
tients were thus allowed time to straighten out
their affairs and in other respects to prepare for
the inevitable and ultimate failure of treatment.

Where uremia is severe when first recognized
and where there has been insufficient time to
make a certain diagnosis or to estimate the prog-
nosis, there is no question that a few treatments
with the artificial kidney are indicated. When the
kidney has failed secondary to poor circulation in
a patient with extensive trauma or after compli-
cated surgery, such as the resection of an aortic
aneurysm or surgery for biliary tract disease, the
results are poor, and the decision as to whether
or not to use the artificial kidney must be care-
fully considered in the light of all of the other po-
tentially lethal non-renal components of the pa-
tient’s problems.

Part of the difficulty in treating such patients
with the artificial kidney is that to be successful,
treatment should probably be started early and
repeated frequently, and the very circumstances

* Lawton, R. L., and Laughlin, L. L.: Treatment of acute
renal insufficiency with special reference to artificial kidney.
j. iowa m. soc., 50:367-372, (Jul.) 1960.

make early diagnosis and prognostication most
difficult. Brief periods of oliguria are common in
seriously ill patients. In spite of all that has been
written, we have no adequate means at present of
diagnosing acute renal failure early, in the pres-
ence of disease involving many organs, or in the
complicated postoperative patient or the severely
traumatized patient. In general, it can be said
that unless renal failure is the single prominent
cause of the patient’s illness, and unless that
renal failure is potentially acute and reversible,
then extracorporeal dialysis should not be con-
sidered.

Another commonly seen patient is the one who
has a rising blood urea nitrogen in spite of a
large urinary output. He will be excreting 1,500 to
2,000 cc. of urine daily. The urine will have a
fixed specific gravity. The patient will have lost
his ability to concentrate or to dilute the urine.
The number of functioning nephron units will
have been markedly reduced, but the remaining
nephrons will function well to maintain this di-
uresis. This patient should not be subjected to
dialysis, for it would alter the renal osmolarity,
inhibit the diuresis and effect an oliguria. He is
best controlled by regulation of food and fluid
intake, along with attention to the details of
fluid management.

Another prominent question these days is wheth-
er a specific patient should be treated in a center
with an artificial kidney or whether peritoneal
dialysis would be equally satisfactory. There is no
certain answer to this question. The answer de-
pends in part upon the severity of the uremia, the
peculiar problems of the patient, and the experi-
ence and attitudes of the moment of those in
charge of the patient’s medical care.

The artificial kidney is more expensive and
complicated. It is also more efficient. Certainly
the patient with severe crush injury should be
treated with the artificial kidney, for it can remove
waste products three times as fast. Even then, re-
peated treatments at intervals of less than 24
hours may be required. For the patient with
chronic uremia, where the rate of catabolism is
less and where the objective is only to prolong life
until a few more diagnostic procedures can be
done, or where an attempt is being made to find
some temporary solution for an insoluble problem,
then probably peritoneal dialysis is to be pre-
ferred, at least by those who are experienced with
it.

TABLE 2

LONG TERM SURVIVAL PERCENTAGES

Per Cent

Selected patients with poisoning

and transfusion

reactions

Remaining patients

Total of entire SUI experience . .

Vol. LII, No. 4

Journal of Iowa Medical Society

207

SOME STATISTICS FROM THE SUI STUDY

In evaluating the overall series, a separate focus
should be considered, and this is presented in
Table 2. It is noteworthy that the overall survival
in the series is 36 per cent. If we were to separate
the patients into two main groups, that is to say

(1) those with chronic intrinsic renal failure, or
renal failure plus severe associated disease, and

(2) those with toxic poisoning reactions and trans-
fusion reactions, we could get a more useful im-
pression.

The long-term recovery of the group with chron-
ic intrinsic renal disease or severe associated dis-
ease is 5 per cent. The long-term survival of the
toxic reaction, poisoning or transfusion-reaction
group is 90 per cent. In breaking down that second
group, we found that the only mortality had been
a boy, previously referred to in this paper, whose
death resulted from a staphylococcal pneumonia
that occurred after diuresis.

Rupture of the

JAMES H. FRUDENFELD, M.D., and
CLIFFORD P. GOPLERUD, M.D.

Iowa City

Rupture of the uterus is a complication of preg-
nancy associated with an alarming maternal and
fetal mortality. Awareness of the predisposing
factors, symptoms and therapy related to this ca-
tastrophe must be reemphasized.

EXPERIENCE AT S.U.I.

In the 35 years from July, 1926, through July,
1960, there were 36,000 deliveries at the State
University of Iowa Hospitals. In that same length
of time, there were 24 instances of rupture of the
pregnant uterus — an incidence of one in every
1,500 deliveries. These figures include both pri-
vate and ward patients.

SPONTANEOUS AND TRAUMATIC UTERINE RUPTURE

There were 10 patients who suffered ruptures
of intact uteri. Four of those phenomena were
spontaneous, and six were traumatic. Of the pa-
tients who experienced spontaneous rupture, in
two it occurred following tumultuous labor. In
the first patient, labor began spontaneously and
proceeded rather slowly until the cervix was 5 cm.
dilated. During the next seven minutes, the pa-
tient had two violent contractions, and delivered.

Dr. Frudenfeld’s present address is 211 North Prairie Ave-
nue, Inglewood, California, and Dr. Goplerud is an asso-
ciate professor in the Department of Obstetrics and Gyne-
cology at the S.U.I. College of Medicine.

CONCLUSION

In the last 2% years, we have come to a better
understanding of some of the immediate problems
involved in the selection and care of patients re-
quiring extracorporeal dialysis. We have noted
that the results are poor in those patients whose
disease is chronic intrinsic renal failure, or renal
failure associated with severe organic disease. The
best results are found in patients whose acute
renal failure is not on the basis of intrinsic irre-
versible renal disease.

We have become aware of the need for early
recognition of the possible candidate for this ad-
junctive therapy, for aggressive treatment of co-
existing conditions, and for attention to accurate
control of fluid intake, measurement of body
weight and protection from pathogenic bacteria.

The artificial kidney is a valuable tool that
should be employed without hesitancy in the se-
lected candidate, and not reserved as a “last ditch”
measure.

Pregnant Uterus

There were extensive vaginal lacerations and a
cervical laceration that extended 4 cm. into the
lower uterine segment. In the second patient, la-
bor had been induced by amniotomy and intra-
venous oxytocin, but the oxytocin had been dis-
continued for some time prior to the end of the
first stage of labor. The second stage lasted only
four minutes, and the contractions were tumul-
tuous. The third patient whose uterus ruptured
spontaneously had been delivered of average-size
infants following her three previous pregnancies.
The fourth labor began spontaneously, and after
15 hours of labor the cervix was 9 cm. dilated, but
the head was not engaged. X-ray pelvimetry re-
vealed measurements within normal range, but
demonstrated fetal hydrocephalus. The hydro-
cephalus was drained, and the infant was delivered
with the aid of fundal pressure after a second
stage of labor lasting one hour and 23 minutes.
The placenta was manually removed, and the
uterus was explored, at which time rupture
through the lower segment was found. This com-
plication was probably due to disproportion, rather
than to the destructive procedure.

The fourth patient whose uterus ruptured spon-
taneously was a 48-year-old para VII whose labor
had begun spontaneously. Early in the labor, it
had been determined that the presentation was of
the right men turn posterior variety. Because the
mother was multiparous and had what was felt
to be an adequate pelvis, a trial of labor was al-
lowed. Labor progressed satisfactorily, and after
seven hours and 45 minutes the cervix was com-
pletely dilated. The position, however, was still
right mentum posterior. A stillborn was delivered

208

Journal of Iowa Medical Society

April, 1962

spontaneously from a mentum anterior position
after a second stage of labor lasting one hour and
17 minutes. Shortly before delivery, the fetal heart
rate decreased, but it returned to normal range
following the administration of oxygen to the
mother. Following delivery, the uterus was ex-
plored and felt to be intact. A cervical laceration
was found and repaired. The patient continued to
bleed vaginally, was cyanotic and hypotensive,
and had a persistent tachycardia. Because of the
continued vaginal bleeding and the patient’s fail-
ure to respond to blood replacement, the uterus
was reexplored and rupture through the lower
segment was found. At that point, the heart
stopped. Open chest massage of the heart was un-
dertaken to no avail while a subtotal hysterectomy
was carried out. The patient died during surgery.
The probable cause of the uterine rupture was
disproportion. There were two possible causes of
death in this instance — hemorrhage from the uter-
ine rupture, or amniotic fluid embolism occurring
after the rupture.

Of the six patients whose uteri were ruptured
by trauma, two were delivered by version and
extraction. Both of these patients had begun to
labor spontaneously. In the first, a transverse lie
was present, and at the time the membranes rup-
tured spontaneously, the umbilical cord prolapsed
into the vagina. While reaching for a foot to per-
form an internal version and extraction, the op-
erator ruptured the uterus. The infant was deliv-
ered alive, but later died.

The second patient had been admitted to the
hospital 24 hours after the spontaneous onset of
labor. At the time of admission, the cervix was
6 cm. dilated, and no fetal heart tones were heard.
Progress was slow during the next eight hours.
At the end of that period, the cervix was 9 cm.
dilated, and the head was in the right occiput
transverse. The Kjelland forceps were applied,
and rotation to the occiput anterior position was
easy. Simpson forceps were then applied, but
after gentle traction no progress was made. In-
ternal version and extraction was done. The in-
fant was hydrocephalic, but no great difficulty
was encountered in delivery of the head. There
was no abnormal bleeding postpartum. The pla-
centa was delivered by simple expression. The
patient was given an intrauterine douche to con-
tract the uterus (1941), and at that time uterine
rupture was found.

In two patients, the use of oxytocin was re-
sponsible for the uterine rupture. Labor was in-
duced in the first of them through the use of
castor oil, quinine and an enema, followed by in-
tramuscular pituitrin in doses of II, III, IV, and
V minims, given at 30-minute intervals. Fifteen
minutes later, strong, frequent contractions began.
Thirty minutes after that, the patient was having
very painful uterine contractions. One hour later,
the presenting part could not be felt on rectal
examination, moderate vaginal bleeding was

noted, and the contractions had ceased. The abdo-
men was very tender; there was flank dullness on
the left; the small parts were readily accessible;
and no fetal heart tones were heard. The patient
showed evidence of shock. At the time of laparoto-
my, a complete uterine rupture and a retroperi-
toneal hematoma were found. The patient had a
total hysterectomy and survived.

The second patient was a 44-year-old para XV
with a breech presentation. The membranes rup-
tured spontaneously at term. Following a latent
period of 24 hours, induction of labor with intra-
muscular oxytocin was begun. One hour later, the
patient began having regular uterine contractions
at four- to five-minute intervals. For unexplained
reasons, the patient was given one minim of
oxytocin intramuscularly two hours after the on-
set of contractions. After a total labor of four
hours and 30 minutes, a viable infant was deliv-
ered by partial breech extraction. Abnormal bleed-
ing followed the delivery, the placenta was re-
moved manually, and a uterine rupture was found.

In the next patient, labor was induced by
amniotomy because of unexplained fetal death at
39 weeks. After a latent period of 21 hours,
dilute intravenous oxytocin was used to inaugu-
rate uterine contractions. After three hours, this
medication was discontinued, but contractions
soon ceased. After a period of observation, a sec-
ond course of intravenous oxytocin was used and
satisfactory uterine contractions were established.
The delivery of a macerated 4,200 Gm. infant was
rather difficult because of shoulder dystocia. On
uterine exploration, an old cervical laceration had
extended into the lower uterine segment. Subse-
quent to the repair of the cervical laceration, a
defect in the lower uterine segment was still palpa-
ble, but despite this finding nothing more was
done. The patient’s immediate postpartum course
was uneventful, and she was discharged from the
hospital on the sixth postpartum day. Two days
later, she was readmitted because of vaginal bleed-
ing. In the hospital, a second hemorrhage occurred,
and examination under anesthesia at that time
confirmed the finding of rupture through the low-
er uterine segment. A total hysterectomy was per-
formed eight days after delivery.

The sixth patient who suffered a traumatic uter-
ine rupture had begun labor spontaneously at
term. After a labor of seven hours and 10 minutes,
the cervix was completely dilated, but the head
was still in the transverse position. After two
hours in the second stage of labor, manual rotation
of the head was attempted, but was unsuccessful.
An attempt was made to apply the Kjelland for-
ceps, but when the operator’s hand was intro-
duced alongside the fetal head, a fetal hand was
also palpable and consequently the forceps were
not applied. An attempt was made to correct the
compound presentation by pushing the hand
cephalad, and subsequently there was no pre-
senting part in the pelvis and a diagnosis of uter-

Vol. LII, No. 4

Journal of Iowa Medical Society

209

TABLE I

Spontaneous

Rupture

Rupture
in Patients
With Previous
Cesarean Section

Age

23, 29, 33, 35,

19, 19, 20, 21, 22,

35, 37, 38, 40,

22, 22, 23, 24, 24,

44, 48

25, 28, 32, 38

Parity

1,1,3, 3, 4, 5,

1, 1, 1, 1, 1, I, 1,

5, 7, 10, 15

2, 2, 2, 2, 3, 4, 10

Prior Surgery Other Than
Section

D&C

Myomectomy

Other

Number of Previous Sections

1.1,1. 1, 1. 1. 1.

Symptoms & Signs of Rupture
Abdominal pain

( 1 -8 days p.p.)

1, 1, 1,2, 2, 2, 4
10

Shock

Vaginal bleeding

Fetal death

Displacement presenting
part

Inertia

Abdominal distention

Types of Surgery
Total hysterectomy

Subtotal hysterectomy

Repair of rupture

Operating Time (Minutes)
T.A.H,

1 10, 1 10, 120,

80, 150, 170

Subtotal

165, 225
80, 100, 120,

60, 62, 90, 90,

120, 120

1 10

Repair

80, 80, 85, 95,

Amount of Blood Required

(Units) by Type of Surgery

105, 122

T.A.H

2,4, 5, 7, 19

0, 4, 4

Subtotal

0, 4, 4, 6, 7

1, 2, 2, 2, 8

Repair

0, 0, 1, 2, 7, 9

Febrile Morbidity by Type of
Surgery (73.9%)

T.A.H.

Subtotal

Repair

Maternal Mortality (4.2%)

Infant Mortality (71%)
Stillborn

Neonatal death

Survivors

ine rupture was made. An immediate total hyster-
ectomy was performed.

The signs and symptoms of uterine rupture in
this group of patients are listed in Table 1.

The interval between the occurrence of the rup-
ture and the diagnosis ranged from 0 minutes to
nine days. The time from diagnosis to the be-
ginning of surgical treatment was determined in
nine instances. It varied from 15 to 30 minutes. All
patients were treated operatively, five having total
and five supracervical hysterectomies. Nine pa-
tients survived. These 10 patients received a total
of 59 units of blood. The postoperative complica-
cations encountered were as follows: one mild
ileus; one wound infection; one thrombophlebitis
in the arm; one pyelonephritis; and six operative
bed infections.

The weight of the infants ranged from 2,755 to
4,655 Gm., and in four instances it was over 4,000
Gm. Six of the infants were stillborn and four
were born alive. One of them died in the neonatal
period, and three were discharged from the hos-
pital in satisfactory condition.

UTERINE RUPTURE FOLLOWING CESAREAN SECTION

There were 14 uterine ruptures in patients who
had had previous cesarean sections. All of them
occurred in classical cesarean section scars. Ten
of the patients had had only one previous abdom-
inal delivery. The indication for the primary ce-
sarean section had been cephalo-pelvic dispropor-
tion in five patients, prolonged labor in three,
uterine inertia in two, and placenta previa in one,
and in two instances the indications for the previ-
ous cesarean section had not been reported.

Eight (57 per cent) of the ruptures occurred
prior to the onset of labor, at 32, 36, 38, 38, 38, 39,
42, and ? weeks’ gestation, respectively. In the
eighth patient it was difficult to determine the
time at which rupture occurred, for there had been
no symptoms. At the time of elective repeat sec-
tion, a 4 x 4 cm. defect was found in the uterine
scar. In the other seven patients, abdominal pain
was the first symptom noted, and only two pa-
tients had vaginal bleeding. On physical examina-
tion, five showed evidence of shock; no fetal
heart was heard in five; abdominal tenderness was
present in three; abdominal distention occurred
in one; and the presenting part was out of the
pelvis in one (See Table 1).

In the other six patients (43 per cent), rupture
occurred after the spontaneous onset of labor. One
patient started labor in the antepartum ward. Dur-
ing the period of preparation for surgery, she
complained of sudden, severe abdominal pain,
and at the time of section an incomplete uterine
rupture was found. In a second patient, a vaginal
delivery was elected in accordance with the pa-
tient’s wishes. During the course of the labor, the
patient complained of exquisite tenderness over
the upper portion of the abdominal scar. When

210

Journal of Iowa Medical Society

April, 1962

the diagnosis of rupture was made, the fetal heart
tones were absent and mild shock was noted.

A third patient began labor while in the hospi-
tal, and because rapid progress had been made by
the time the operating room could be prepared,
vaginal delivery was elected. The first stage of
labor lasted four hours and 25 minutes, and deliv-
ery was accomplished by low forceps after a sec-
ond stage of 12 minutes. Exploration of the uterus
following delivery of the placenta revealed uterine
rupture.

The fourth patient was admitted to the hospital
five and one-half hours after the onset of contrac-
tions. During a period of observation, few contrac-
tions were noted. Subsequent examinations re-
vealed the cervix to be 5 cm. dilated. It was de-
cided to deliver the patient vaginally. One hour
later, the cervix was completely dilated, the head
at plus two station, and the occiput in the right
posterior portion of the maternal pelvis. One and
a quarter hours later, the patient was anesthetized
by the “saddle block” technic for forceps rotation
and delivery. While the position of the head was
being confirmed, bloody amniotic fluid passed from
the vaginia, and the presenting part was found to
be out of the pelvis. Uterine rupture was diag-
nosed.

The fifth patient was admitted to the hospital in
shock three and one-half hours after labor had
begun spontaneously while she was at home.

The sixth patient began having abdominal pain
at home, and after several hours developed rhyth-
mic uterine contractions, but they ceased rather
suddenly two hours later. She was admitted to
this hospital four days afterward. On initial exam-
ination the fetal heart tones were absent and the
abdomen was tender. Fetal parts were easily
palpated. The diagnosis of uterine rupture was
made, and it was confirmed at laparotomy.

The symptoms of uterine rupture were abdom-
inal pain in three and vaginal bleeding in two.
The signs at examination were fetal death in four,
shock in four, uterine inertia in three, displace-
ment of presenting part in three, increased ac-
cessibility of small parts in two, and abdominal
tenderness in one (See Table 1).

The elapsed time from diagnosis to the start of
surgical treatment ranged from 12 to 90 minutes.
The treatment consisted of subtotal hysterectomy
in five instances, total hysterectomy in three, re-
pair of the uterus and tubal sterilization in one,
and repair of the uterus in five. ( Of those repaired,
two have had subsequent pregnancies. One of
these had no difficulty in the next pregnancy, but
in the other patient the uterus ruptured again.
The latter patient appears as two cases in this
report.) These 13 patients received zero to nine
transfusions, and the total of the transfusions for
all patients was 42 (See Table 1).

Of these 13 patients, 11 had febrile postopera-
tive courses, one had a wound infection, one had
pyelonephritis, one had an adynamic ileus, pylo-
nephritis, pneumonia and pelvic thrombophlebitis,

and one had pulmonary edema from overtrans-
fusion. All six patients whose ruptures were re-
paired were febrile, whereas five of the eight who
had either total or subtotal hysterectomies were
febrile.

The infants varied in weight from 2,190 to 5,000
Gm., only two weighing more than 4,000 Gm. Nine
of the infants were stillborn. The other five were
born alive. One died in the early neonatal period
from atelectasis, and the other four were dis-
charged from the hospital in satisfactory condi-
tion.

DISCUSSION

The incidence of rupture of the pregnant uterus
is reported as being from 1:22015 to 1:30 2923 deliv-
eries. However, the majority of reports demon-
strate that this complication occurs about once in
every 2,000 deliveries, as shown in Table 2. Ma-
ternal mortality ranges from 4 per cent18 to 61 per
cent.23 Fetal mortality in association with uterine
rupture varies from 29.4 per cent20 to 89 per cent.3
In the present series, the maternal mortality was
4.2 per cent, and the perinatal loss 71 per cent (See
Table 2) .

Important etiologic factors are previous uterine
surgery, such as cesarean section and myomec-
tomy, trauma secondary to operative vaginal de-
liveries, and the use of oxytocin. All of these are
represented in this series, with previous cesarean
section being the outstanding predisposing factor.
Version and extraction in most instances is being
replaced by other modes of therapy, except for
occasional use in delivering a second twin and de-
livering immatures or small prematures in con-
junction with complications such as transverse lie
and/or partial placenta previa.

Oxytocin, used to initiate or stimulate uterine
contractions, is an important therapeutic tool, and
when given judiciously for an appropriate indica-
tion and under appropriate conditions, need not
jeopardize the patient or the infant.

Previous unrecognized uterine trauma must play
an important role in spontaneous rupture, but it is
virtually impossible to authenticate.

It is interesting to note that all 14 uterine rup-
tures following cesarean section occurred through
classical scars. Throughout the area from which
these patients are referred, it is probable that the
most common procedure for abdominal delivery
is the classical cesarean operation.

Although the common symptoms and findings
of pain, shock and fetal death were well demon-
strated in those patients who had uterine scars,
such was not the case with the patients with
previously intact uteri, for in them bleeding and
shock were most common. Displacement of the
presenting part and cessation of labor were also
important findings.

Reduction in the lapse of time from rupture to
diagnosis — requiring an awareness of the possibil-
ity of this complication — and reduction in the
lapse of time from diagnosis to treatment — requir-

Vol. LII, No. 4

Journal of Iowa Medical Society

211

TABLE 2

Author

Incidence
of Uterine
Rupture

Maternal
Mortality
( Per Cent)

Fetal
Mortality
( Per Cent)

Bill, Barney, Melody . .

1:2756

Sheldon

1:1829

42.3

Lynch

1:1118

Beacham and Beacham

1:1328

47.9

79.6

Brierton, Philipp, and

Webster

1:1961

33.3

66.7

Morrison and Douglas .

1:1465

42.2

77.7

Meredith

1 : 1 588

1 l.l

33.3

Bak and Hayden

1:1375

Maisel

1 : 1929

27.2

81.6

Voogd, Wood and Powell

1:1432

8.4

63.6

Burkons

10.8

61.5

Posner, Smith and Trambert 1:2724

57.1

85.7

Dugger

1:3029

Fitzgerald, Webster and
Fields

1:2196

54.8

79.1

Delfs and Eastman

1:1010

47.1

80.0

Whitacre and Fang .

1:220

56.8

Jacobs, Cunningham, Daily
and Conner

1 :2402

12.2

Golden and Betson

1:1572

8.7

41.7

Posner, Santos, Posner . . .

1:1274

Pedowitz and Perrell ....

1:1508

14.9

33.3

Ferguson and Reid

1:1204

5.9

29.4

Ware, Jerrett and Reda

1:1771

67.5

Erving

1:2598

29.7

62.5

Frudenfeld and Goplerud

1:1500

4.2

ing adequate physical facilities, personnel and de-
cisiveness of action — are of prime importance in
treating rupture of the uterus.

After the diagnosis of uterine rupture has been
made, immediate surgery is indicated. If the pa-
tient is in shock, a cut down is indicated, and blood
should be pumped in. One cannot wait for the pa-
tient to come out of shock before performing sur-
gery, since major vessels are the source of bleed-
ing. If possible, a total hysterectomy is preferable
to a subtotal one, because of the vaginal and
cervical lacerations that may have been sustained
in the rupture.

In the patient whose rupture occurs through a
cesarean section scar, one must consider uterine
preservation if the defect is not too large, if the
blood loss has not been excessive, and if the pa-
tient desires additional children. One must recog-
nize the danger of subsequent rupture. This oc-
curred in one patient in this series.

SUMMARy AND CONCLUSIONS

1. A series of 24 uterine ruptures, with a ma-
ternal mortality of 4.2 per cent and a fetal mor-
tality of 71 per cent, has been presented. A tabular
summary of other reported series is appended.

2. Factors which predispose to rupture of the
pregnant uterus include previous cesarean sec-
tion, traumatic operative delivery and the use
of oxytocin.

3. A preponderance of ruptures has been shown
to occur through classical cesarean scars, but this
should not be thought to indicate that they cannot
occur through other types of scars.

4. The necessity for awareness of this complica-
tion, the importance of the time lapses from rup-
ture to diagnosis and from diagnosis to treatment,
as well as the availability of the physical facilities
and personnel for emergency surgical therapy,
have been stressed.

5. The place of repair of the ruptured cesarean
scar, in relation to the patient’s condition, her
parity and her desire for further childbearing, has
been discussed.

ACKNOWLEDGEMENT

We wish to thank Dr. W. C. Keettel for his as-
sistance in the preparation of this manuscript.

REFERENCES

1. Bill, A. H., Barney, W. R., and Melody, G. F.: Rup-
ture of uterus, Am. J. Obst. & Gynec. 47:712-717, (May)
1944.

2. Sheldon, C. P.: Record of 26 cases of rupture of uterus.
Am. J. Obst. & Gynec. 31:455, (Mar.) 1936.

3. Lynch, F. J.: Rupture of uterus, Am. J. Obst. & Gynec.
49:514-531, (Apr.) 1945.

4. Beacham, W. D., and Beacham, D W. : Rupture of

uterus, Am. J. Obst. & Gynec. 61:824-839, (Apr.) 1951.

5. Brierton, J. F.: Rupture of pregnant uterus, Am. J.
Obst. & Gynec. 59:113-124, (Jan.) 1950.

6. Morrison, J. H., and Douglas, L. H.: Rupture of uterus.
Am. J. Obst. & Gynec. 50:330-335, (Sept.) 1945.

7. Meredith, R. S.: Ruptured uteri at Woman’s Hospital,
Am. J. Obst. & Gynec. 70:84-92, (July) 1955.

8. Bak, T. F., and Hayden, G. E.: Rupture of pregnant
uterus, Am. J. Obst. & Gynec. 70:961-971, (Nov.) 1955.

9. Maisel, F. J.: Rupture of gravid uterus; 10-year survey.
Am. J. Obst. & Gynec. 72:25-30, (July) 1956.

10. Voogd, L. B„ Wood, H. B., and Powell, D. V.: Rup-
tured uterus, Obst. & Gynec. 7:70-77, (Jan.) 1956.

11. Burkons, H. F.: Ruptured uterus, Obst. & Gynec. 7:675-
683, (June) 1956.

12. Posner, L. B., Smith, D. F.r and Trambert, H. L.: 14-
year survey of parturient ruptured uterus at Harlem Hos-
pital, New York J. Med. 51:641-644, (Mar. 1) 1951.

13. Fitzgerald, J. E., Webster, A., and Fields, J. E.: Rup-
tured uterus; report of 42 cases, Surg. Gynec. & Obst. 88:-
652-660, (May) 1949.

14. Delfs, E., and Eastman, N. J. : Rupture of uterus,
Canad. M. A. J. 52:376-381, (Apr.) 1945.

15. Whitacre, F. E., and Fang, L. Y.: Management of
rupture of uterus; report of 44 cases. Arch. Surg. 45:213-234.
(Aug.) 1942.

16. Jacobs, W. M., Cunningham, J. E., Daily, H. I., and
Conner, J. S.: Third-trimester rupture of pregnant uterus;
five-year survey, Obst. & Gynec. 19:16-21, (Jan.) 1962.

17. Golden, M. L., and Betson, J. R.: Rupture of uterus;
18-year survey, Obst. & Gynec. 13:506-512, (Apr.) 1959.

18. Posner, L. B., Santos, J. R., and Posner, A. C.: Rupture
of uterus, Obst. & Gynec. 13:288-293, (Mar.) 1959.

19. Pedowitz, P., and Perell, A.: Rupture of uterus. Am.
J. Obst. & Gynec. 76:161-171, (July) 1958.

20. Ferguson, R. K., and Reid, D. E.: Rupture of uterus;
twenty-year report from Boston Lying-In Hospital, Am. J.
Obst. & Gynec. 76:172-180, (July) 1958.

21. Ware, H. H., Jarrett, A. Q., and Reda, F. A.: Rupture
of gravid uterus; report of 40 cases. Am. J. Obst. & Gynec.
76:181-187, (July) 1958.

22. Erving, H. W.: Rupture of uterus, Am. J. Obst. &
Gynec. 74:251-258, (Aug.) 1957.

23. Dugger, J. H. : Symposium on recent advances in
gynecology and obstetrics; ruptured uterus in last trimester
of pregnancy; report of 105 cases, S. Clin. North America
25:1414-1424, (Dec.) 1945.

Correlation Between

Cord Blood Oxygen Values and
Psychological Test Scores

DONAL DUNPHY, M.D.
Iowa City, and
VIVIAN PESSIN
Buffalo, New York

A causal relationship between hypoxia and cen-
tral nervous system damage has been convincingly
demonstrated by animal experimentation. Windle
and Becker,1 using pregnant guinea pigs, demon-
strated that induced hypoxia in utero was followed
by gross neurological damage, detectable be-
havioral differences and inferior learning ability
in the offspring. However, even with this experi-
mental design that controlled many variables, the
extent of impairment was not always predictable
from the degree of hypoxia.

The relationship between hypoxia and central
nervous system damage in human infants is less
clear. Retrospective studies in human beings have
yielded conflicting evidence of a relationship be-
tween presumed hypoxia in infancy, and neurolog-
ical and behavioral abnormalities in childhood.2’ 3

Two prospective studies designed to investigate
the relationship between blood oxygen saturation
values in newborn infants and subsequent be-
havior or test scores produced negative findings.
Apgar et al ,4 failed to find a relationship between
02 content of blood drawn in the first three hours
after birth and either Gesell development ratings
at approximately two years of age or revised Stan-
ford-Binet IQ’s at approximately five years of
age. Caldwell et al.5 found no relationship between
02 saturation of cord or heel blood collected dur-
ing the first hour of life and performance on be-
havioral tests between two and four days of age.

This paper reports the findings in another pros-
pective study, based on an analysis of the correla-
tion between cord blood oxygen saturation levels

Dr. Dunphy is the new head of the Department of Pediat-
rics at the SUI College of Medicine. The data for this report
were derived from the Child Growth Study developed through
the cooperative efforts of the Department of Pediatrics and
Obstetrics of the University of Buffalo School of Medicine
and the New York State Department of Health.

and subsequent intellectual maturation as meas-
ured by psychometric test scores.

MATERIALS AND METHODS

The general plan of the Buffalo Children’s Hos-
pital Child Growth Study has been described else-
where.6 All infants in the study were born at
Children’s Hospital, Buffalo, New York, between
September 1, 1949, and December 31, 1953. Initial-
ly, the only criteria for admission to the study pro-
gram were the consent of the parents and the con-
venience of the staff — i.e., the majority of children
included were born in the daytime. Subsequently,
preference was given to unusual cases, such as
breech, operative forceps and cesarean section
deliveries.

The differences between the study group and
the total hospital population are shown in Table 1.
In the study group there were relatively more
individuals born by cesarean, operative forceps
and breech deliveries, and fewer born by spon-
taneous and low forceps deliveries. These differ-
ences preclude direct generalization claiming that
the study findings are typical of what might be
found in the total hospital population.

Infants were classified as premature if their
birth weights were less than 5 lbs. 8 oz., and if
their gestations had been less than 42 weeks. The
number of premature infants with adequate data
for this study was small. There were 329 children
with known umbilical vein blood oxygen satura-
tion ranging from five to 93 per cent and with at
least one psychological test score before five years
of age. The scores ranged from 49 to 159. Seventy-
four per cent of the children had had at least five
of a possible seven psychological tests, and 38 per
cent had completed all of them. The psychologists
were able to obtain scores from 96 per cent of the
total tests made. There were 63 additional children
whose parents had refused follow-up studies but
who were induced to return for a single visit at
the termination of the program. The data for those
children influenced the study results at the five-
year level only.

The infants received a physical examination
following delivery. The study plan also included
follow-up visits at 6, 12, 24, 36, 48 and 60 months

212

Vol. LII, No. 4

Journal of Iowa Medical Society

213

TABLE I

TYPE OF DELIVERY OF LIVE BIRTHS, STUDY GROUP
AND TOTAL HOSPITAL, 1949-1953

Total Hospital

Study Group Experience

(1949-1953) (1949-1953)

Type of Delivery

Number
of Live
Births

Per Cent
of Live
Births

Number
of Live
Births

Per Cent
of Live
Births

Total

329

100.0

12,829

100.0

Spontaneous

5.2

1,293

10.1

Low Forceps

200

60.8

9,437

73.5

Cesarean Section

16.1

482

3.8

Breech and Versions

9.1

780

6.1

Operative Forceps .

8.8

837

6.5

of age, for physical and modified neurologic exam-
inations, an electroencephalogram, a psychometric
test and psychological examinations, and at 18
months for the psychometric test only.

The Cattell Infant Intelligence Scale was ad-
ministered to all children from six through 18
months of age, and to some of the children at 24
months of age. Form L or M of the Stanford-Binet
was used alternately for all other tests. The ma-
jority of children were tested within a month of
the designated age. The chronological age to the
nearest tenth of a month was used in scoring the
Cattell Infant Intelligence Scale, and the Stan-
ford-Binet was scored in the usual fashion.

Three measurements of cord blood oxygen sat-
uration were obtained: vein oxygen saturation,
which is presumably a measure of oxygen avail-
able to the infant through placental exchange; the
difference between vein and artery oxygen satura-
tion (A-V difference), a partial index of oxygen
utilization by the infant; and arterial oxygen sat-
uration, an index of the saturation of the blood re-
turning to the placenta. These determinations, al-
though precise, are limited indications of the oxy-
gen economy of the infant. They do not measure
volume and rate of flow, and are single measure-
ments of levels known to be variable.

Ninety per cent of the cord blood samples were
obtained within one minute of the infant’s deliv-
ery, from doubly-clamped cord sections approxi-
mately 12 inches in length. The blood samples
were collected anerobically from the cord vein
and artery in separate heparinized syringes con-
taining a drop of mercury. The syringes were im-
mediately capped, shaken and placed in refrigera-
tion. Van Slyke manometric gas analyses were
performed in duplicate, usually within four hours
and always within 12 hours, for determination of
cord vein and artery 02 content and capacity. The
percentage of 02 saturation was calculated.7

RESULTS

The ranges for IQ scores at ages six months and
five years, and the ranges of cord vein and artery

TABLE 2

RANGES OF IQ TEST SCORES AND
CORD BLOOD VALUES

Ranges

Vein

Artery

6 Months

5 Y ears

Mature

4.5%-92.4%

0.0%-69.3%

60-131

60-159

Premature

8.8%-92.6%

3.5%-63.3%

49-113

57-134

02 saturations at birth are given in Table 2. There
are wide ranges in both cord blood values and
IQ test scores. The test scores for the premature
infants are lower than are those for mature in-
fants, although the cord blood values are similar.

Correlations between IQ test scores and vein 02
saturation are given in Table 3, by maturity. The
correlations are statistically significant for the
mature infants and for the total group at six
months through 18 months, ranging from .14 to .19.
The correlations are positive though not statisti-
cally significant, ranging from .03 to .13, at the
other ages. No statistically significant correlation
was found in the premature group. The differences
between the correlations for mature and prema-
ture infants could not be explored with our data
because of the limited number of premature in-
fants. The prematures have been excluded from
subsequent analyses because of the small numbers
for whom complete data are available, and because
of the differences in the degrees of maturity with-
in that group.

The correlations of IQ test scores with arterial
02 saturation, with A-V difference and with vein
02 saturation are given in Table 4. Fewer cases
were available for this analysis since it was not
possible to obtain arterial samples in every case.
The only correlations significantly different from
zero were with vein 02 saturation.

It is possible that the positive correlation ob-
served between cord vein oxygen and IQ scores
(Tables 3 and 4) may not reflect a direct relation-

TABLE 3

CORRELATIONS BETWEEN IQ AND CORD VEIN
BLOOD O, SATURATION BY AGE AND TYPE
OF TEST, AND BY MATURITY AT BIRTH

Type of Test:
Age in Years:

'/2

Cattell
1 1 '/ 2

Stanford-Binet
2 3 4 5

Correlation Co

efficient

All cases

.14*

.16*

.19*

.03

.05

.13

.09

.07

Mature

.18*

.16*

.19*

.00

.03

.10

.06

.05

Premature -

-.17

.04

.03

.29

.12

.32

.26

.17

Number of Cases

All cases

311

272

233

134

216

219

263

Mature

277

243

210

121

193

196

241

Premature

* Significantly different from zero at the 5% level.

214

Journal of Iowa Medical Society

April, 1962

ship, but only the effect of a relationship of both
of these with either arterial oxygen saturation or
A-V difference, since these cord blood values are
all interrelated. This possibility was explored
through a study of partial correlations, which may
be thought of as the correlation between two vari-
ables with the effect of a third variable held con-
stant. In Table 5, the total and partial correlations
are listed for mature infants with the necessary
data.

When the effect of arterial 02 is eliminated from
the correlation of IQ with vein 02 (line 2, Table
5), the correlations remain virtually unchanged.
This means that the correlations are not an in-
direct consequence of correlation between IQ and
artery 02. Similarly, the removal of the effect of
A-V difference from the correlations does not alter
the correlation with vein 02 (line 3, Table 5).
However, when the effect of vein 02 levels is
eliminated from the correlations of IQ with artery
02 (line 5, Table 5) or from the correlation of IQ
with A-V difference (line 8, Table 5), the cor-
relations diminish. This suggests that the primary
relationship is that between IQ and vein 02, and
the correlations of IQ with the other two measure-
ments are mainly a consequence of the correlation
these measurements and vein 02 levels.

Since it has been demonstrated8 that the vein
saturation is generally lower in the group sampled
before respiration than in the group sampled after
the onset of respiration, the correlations for these
two groups were compared (Table 6). Neither of
the differences between the two groups is statis-
tically significant.

The correlations found between IQ test scores
and cord vein 02 saturation cannot be explained
by the inclusion of a disproportionate number of
adverse delivery situations. The group delivered
by cesarean section is the only group that differs
statistically (P < .02) from the spontaneous and
low-forceps delivery groups, as far as the mean
cord vein 02 saturation is concerned (Table 7).
Furthermore, a review of the correlation tables
failed to reveal any localization of association.

TABLE 4

CORRELATIONS BETWEEN IQ AND CORD BLOOD 02
SATURATIONS OF INFANTS MATURE AT BIRTH, BY AGE

Type of Test:
Age in Years:

'/ 2

Cattell
1 |l/2

Stanford-Binet
3 4 5

No. of Cases**

220

191

165

147

151

198

Correlation Coe

fficient

IQ With O,

Saturat

ion

Vein

.18*

.08

.16*

-.12

.00

.06

.01

Artery

.12 -

.04

.10

-.12

-.05

.07

.01

A-V difference

.10

.14

.10

-.04

.05

.01

.00

.01

* Significantly different from zero at the 5% level.
** With both vein and artery 0 > determinations.

Thus, the association is not limited to low 02 sat-
urations and low IQ’s.

There were five infants with very low psycho-
logical test scores, but these scores were not all
associated with low cord vein 02 saturations. One
was a congenital cretin with a test score of 49 and
a cord vein oxygen saturation of 59.6 per cent.
That infant was a twin whose sibling was entirely
normal. Another infant had a test score of 55 at
six months of age. That infant was born with se-
vere erythroblastosis, and had an initial hemo-
globin of approximately 10 Gm. and an 02 satura-
tion of 34. 8 per cent. That infant died at a mental
institution with severe neurological impairment,
presumably due to kernicterus. The third baby
had a test score of 57 and had been premature,
weighing 3 lbs. 6 oz. at birth. The cord vein 02
saturation was 44.5 per cent. That infant devel-
oped retrolental fibroplasia. Although some light
perception is present, psychological testing was
difficult and not necessarily representative of the
child’s ability. Subsequent observations, however,
indicate that the child is truly defective. A fourth
child attained a test score of 60. That infant was a
triplet and had a birth weight of 5 lbs. 8 oz. The
cord vein 02 saturation was 45.0 per cent. There
were no specific findings either on physical or on
neurologic examination to account for the low
test scores. The sibling triplets tested in the dull-
normal range. The fifth child achieved a test score
of 60. Delivery had been by elective cesarean sec-
tion. The infant had aspirated a considerable

TABLE 5

CORRELATIONS AND PARTIAL CORRELATIONS
BETWEEN IQ AND CORD BLOOD O, SATURATIONS OF
INFANTS MATURE AT BIRTH, BY AGE

Type of Test:
Age in Years:

Cattell Stanford-Binet

1 1 1/2 2 2 3 4 5

1. Corr. between IQ
and vein 02

.18*

.08

. 1 6* — . 1 2 .00

.06

.01

2. Effect of artery
O:; elim.

.14*

.13

.12 -.06 .04

.02

.00

.01

3. Effect of

diff. elim.

.15*

-.01

.13 -.13 -.04

.07

.01

4. Corr. between IQ
and artery 02

.12

-.04

.10 -.12 -.05

.07

.01

5. Effect of vein
02 elim.

.01

-.12

.01 -.04 -.07

.04

.00

6. Effect of diff. elim.

7. Corr. between IQ

and diff. in O2 .10

.14

( Same as line 3
.10 -.04 .05

| **
.01

.00

.01

8. Effect of vein
O2 elim.

( Same as

line 5, with opposite

signs]

9. Effect of artery
O 2 elim.
Number of Cases:

220

191

( Same as line 2
165 59 98

I **

147

151

198

* Significantly different from zero at the 5% level.

** This is a consequence of the relationship A-V diff. =
Vein minus Artery.

Vol. LII, No. 4

Journal of Iowa Medical Society

215

amount of amniotic fluid and had presented a
problem in resuscitation, with persistent and in-
tense cyanosis for eight minutes. The cord vein
02 saturation was 26.4 per cent. That infant has
no abnormal findings on physical examination, but
has generalized seizures and a grossly abnormal
electroencephalogram.

DISCUSSION

The problem of oxygen deprivation in animals,
and very probably in. the newborn infant, is com-
plex. A variety of factors are involved, rather than
simply the direct effects of oxygen deprivation
upon central nervous system tissue.9-13 The extent
to which these variables modify the effect of hy-
poxia in the newborn infant has not been eluci-
dated. It is not surprising, therefore, that there is
a great deal of apparently conflicting evidence
concerning the relationship between hypoxia in
infants and central nervous system damage.

The data presented in this paper demonstrate
a positive correlation between the oxygen satura-
tion of blood taken from the umbilical vein at
birth and psychological test scores in infancy and
early childhood. The correlations are statistically
different from zero at six, 12 and 18 months of
age. At ages two, three, four and five years, the
correlations remain positive, but are not statis-
tically significant. It should be emphasized that
the positive correlation, although of a low magni-
tude, is a general one. It exists throughout the
scale of 02 saturations and IQ’s.

As stated above, different tests were used as
bases for estimates of IQ in the children at ages
under two and over two years. Since the Stanford-
Binet is not constructed for use with children
whose mental ages are less than two years, the
Cattell Infant Intelligence Scale was used for the
younger children. Hence it is impossible to deter-
mine from this study whether the lower correla-
tions at ages three to five years are due to the dif-

TABLE 6

CORRELATIONS BETWEEN CORD VEIN BLOOD O:
SATURATION OF INFANTS MATURE AT BIRTH,
AND IQ BY AGE, AND BY TIME OF
CORD BLOOD SAMPLING

Type of Test:
Age in Years:

Cattell

Stanford-Binet

Correlation Coefficient

Sampled before respiration

23*

.08

Sampled after respiration . . . .

.00

Number of Cases

Sampled before respiration

. ... 153

147

Sampled after respiration

119

Time of sampling not known

ference in tests, to a diminution with age in the
effect of hypoxia at birth, or to other factors, in-
cluding chance.

The finding of significant positive correlations
is surprising in view of the complexity of the
problem, the limitations of the methods employed
and other factors that are known to have been
operative and that could have masked these cor-
relations. Heredity, environment, physical and
emotional health — all of these are known to affect
psychometric test scores. The diminution in the
observed correlations at later ages could, in part
at least, be explained by the increasing influence
that some of these factors exert as youngsters
grow older. The low magnitude of the correlation
coefficients indicates the unpredictability of an
individual infant’s intellectual development on
the basis of his cord blood oxygen values.

Work reported by Pennoyer et al ,14 and by this
group0 have demonstrated the rapid rise of 02
saturation after birth. For example, in this study
the average 02 saturation rose from 51 per cent
in the cord vein blood to 90 per cent 25 minutes
after birth, as determined by ear-piece oximetry.0
Because of the rapidity of this change, measure-
ments taken at different times after birth are not
comparable and well may differ in their implica-
tions.

This characteristic of 02 saturation may partially
explain the absence of demonstrable correlations
in the studies by Apgar4 and Caldwell et al.5
Those studies, although resembling this one in
purpose, have important differences in design that
may account for the differences in results. The
study by Caldwell et al. differs basically in that
the investigators correlated oxygen saturation val-
ues obtained through the first 10 minutes of life
with behavioral tests of newborn infants that
were usually performed 24-48 hours post-delivery.

Apgar’s study differs in several respects. First,
cord blood samples were obtained after delivery
of the placenta. Second, the correlations of Stan-
ford-Binet test scores with cord blood values most
nearly comparable in time of collection to those in
our study included data on blood samples taken
up to 4.9 minutes after birth, whereas the blood
samples for our study were all collected within

TABLE 7

PER CENT OXYGEN SATURATION OF CORD VEIN
BLOOD AND RANGE BY TYPE OF DELIVERY

Type of Delivery

Number

Mean

Range

Spontaneous

54.9

4.5-83.4

Low Forceps

200

54.1

8.8-92.4

Cesarean Section

36.4

8.0-92.6

Breech and Versions

48.0

1 1.1-82.5

Operative Forceps

50.4

12.9-70.1

Significantly different from zero at the 5% level.

216

Journal of Iowa Medical Society

April, 1962

one minute following delivery. Furthermore, in
Apgar’s study there were only 78 cases, including
a variety of age levels, for correlation studies. The
cases tested in the younger age groups were ap-
praised by means of Gesell development ratings.
This group was composed of infants whose blood
oxygen values had been obtained between 0 and
10 minutes after birth, and the lowest oxygen
value found was used for correlation with the test
scores. Thus there is again a difference in times
of sampling, the number of cases studied was
small (65), and test scores at ages from 21 to 34
months were grouped for correlation studies.

The work of Dawes et al.15 on the fetal circula-
tion of the lamb and of James et al. on that of
infants suggest that oxygen saturation in the um-
bilical cord artery is indicative of the oxygen
saturation available to the fetal tissues. However,
we were unable to demonstrate any significant cor-
relation of this oxygen saturation with subsequent
test scores. Furthermore, analysis by partial corre-
lation technics of the interrelationships among
vein, artery and A-V difference values indicates
that vein oxygen saturation is the primary factor
in the relationship found between IQ test scores
and cord blood oxygen values.

SUMMARY

Data has been presented establishing a positive
correlation, of a low order of magnitude, between
cord vein oxygen saturation values at birth and
subsequent psychological test scores of children.
The correlation was found to be statistically sig-
nificant in children at 6, 12 and 18 months of age.
Thereafter, a positive correlation persisted, but did
not achieve statistical significance. These data can-
not be regarded as constituting proof, but they do
suggest a relationship between anoxia and low test
scores. However, the magnitude of the relationship
is too low to be clinically useful in predicting
future mental development of the individual infant
from his cord blood oxygen values. No statistically
significant correlation between IQ scores and ei-
ther artery or A-V difference in cord blood oxygen
values was found.

The demonstration of a positive correlation be-
tween umbilical vein blood oxygen saturation and
IQ scores suggests that further study of the prob-
lem would be justified. In view of the low order of
magnitude of the correlations found, it would
appear desirable to employ more precise param-
eters of hypoxia than are provided by umbilical
vein and artery oxygen saturations.

REFERENCES

1. Windle, W. F., and Becker, R. F.: Asphyxia neonatorum;
experimental study in guinea pig. Am. J. Obst. & Gynec.
45:183-200, (Feb.) 1943.

2. Rosenfeld, G. B., and Bradley, C.: Childhood behavior
sequelae of asphyxia in infancy; with special reference to
pertussis and asphyxia neonatorum. Pediatrics 2:74-84, (July)
1948.

3. Keith, H. M., and Norval, M. A.: Neurologic lesions in
newly bom infant; preliminary study; role of prolonged
labor, asphyxia and delayed respiration. Pediatrics 6:229-242,
(Aug.) 1950.

4. Apgar, V., Girdany, B. R., McIntosh, R., and Taylor,
H. C., Jr.: Neonatal anoxia; study of relation of oxygenation
at birth to intellectual development. Pediatrics 15:653-661,
(June) 1955.

5. Caldwell, B. M., Graham, F. K., Pennoyer, M. M., Ern-
hart, C. B., and Hartmann, A. F.: Utility of blood oxygena-
tion as indicator of postnatal condition. J. Pediat. 50:434-445,
(Apr.) 1957.

6. MacKinney, L. G., Ehrlich, F. E., and Chase, H. C.: Study
of factors affecting neurological status of young children;
plan of study and some neonatal findings. Am. J. Pub. Health
45:653-661, (May) 1955.

7. VanSlyke, D. D., and Neill, J. M.: Determination of gases
in blood and other solutions by vacuum extraction and mano-
metric measurement. J. Biol. Chem. 61:523-573, (Sept.) 1924.

8. MacKinney, L. G., Goldberg, I. D., Ehrlich, F. E., and
Freymann, K. C.: Chemical analyses of blood from umbilical
cord of newborn; relation to fetal maturity and perinatal dis-
tress. Pediatrics 21:555-564, (Apr.) 1958.

9. Himwich, H. E., Alexander, F. A. D., and Fazekas, J. E.:
Tolerance of newborn to hypoxia and anoxia. (Abst.) Am.
J. Physiol. 133:327-328, (June) 1941.

10. Villee, C. A., Hagerman, D. D., Holmberg, N., Lind, J.,
and Villee, D. B.: Effects of anoxia on metabolism of human
fetal tissues. Pediatrics 22:953-970, (Nov.) 1958.

11. Cooke, R. E.: “Physiology of Asphyxia Neonatorum.” In:
Windle, W. F., ed.: Neurological and Psychological Deficits of
Asphyxia Neonatorium. Ch. VII, pp. 88-104, Springfield, 111.,
Charles C Thomas, 1958.

12. Thorn, W., and Heitmann, R.: pH der Gehimrinde vom
Kaninchen in situ wahrend perakuter, totaler Ischamie, reiner
Anoxie und in der Erholung. Arch. ges. Physiol. 2 5 8:501-510,
1954.

13. Geiger, A.: Correlation of brain metabolism and func-
tion by use of brain perfusion method in situ. Physiol. Rev.
38:1-20, (Jan.) 1958.

14. Pennoyer, M. M., Graham, F. K., and Hartmann, A. F.:
Relationship of paranatal experience to oxygen saturation in
newborn infants. J. Pediat. 49:685-698, (Dec.) 1956.

15. Dawes, G. S., Mott, J. C., and Widdicombe, J. G. :
Foetal circulation in lamb. J. Physiol. 126:563-587, (Dec.)
1954.

16. James, L. S., Weisbrot, I. M., Prince, C. E., Holaday,
D. A., and Apgar, V.: Acid-base status of human infants in
relation to birth asphyxia and onset of respiration. J. Pediat.
52:379-394, (Apr.) 1958.

AMA Attempts to Universalize
Medical Terms

A paper back, pocket-size guide to the pre-
ferred medical terms of all important diseases will
be published in June by the American Medical
Association. It will represent the first step in de-
veloping a system of correct medical terminology
so physicians from all parts of the world can
understand each other, Burgess L. Gordon, M.D.,
AMA’s director of nomenclature, said.

Entitled current medical terminology, the book
will provide a definition of each disease with the
known or possible causes and the most character-
istic disturbances and findings. Through frequent
revision — an updated revision is anticipated every
year or 18 months — the book will serve as a focal
point of expanding medical knowledge.

The first edition of current medical terminol-
ogy will sell for just $2.00, and its fewer than 500
pages will list alphabetically 4,000 diseases and
conditions, including psychological and neurolog-
ical disorders, and definitions based on what is
generally considered established data.

The new publication was designed as a com-
panion to STANDARD NOMENCLATURE OF DISEASES AND

operations (SNDO), the official disease listing
published every 10 years since 1928, which in re-
cent years has become “excessively large and
complicated.”

State University of Iowa
College of Medicine

Clinical Pathologic Conference

SUMMARY OF CLINICAL FINDINGS

A 67-year-old, white retired farmer was first ad-
mitted to the University Hospitals on August 24,
1960, because of drowsiness and lack of energy
throughout the entire summer of 1960. During
July, he had become dizzy while arising. He had
been hospitalized elsewhere on August 1, 1960,
after having passed blood in his urine twice, but
on that admission his urine had not contained any
blood. Findings at that time were reported to have
shown the following: increased density in the right
lower lobe on a chest film; negative gastrointes-
tinal series; a “widened” abdominal aorta; and a
nonprotein nitrogen of 116.5 mg. per cent, which
was interpreted by a urological consultant as pre-
cluding the taking of intravenous pyelograms. No
other results of the urological consultation were
reported. Fluids were forced, “shots” were given,
and the patient began to feel better. He lost 14
lbs., and noted some cold intolerance for two weeks
prior to his admission here.

On the patient’s admission to University Hos-
pitals, the following additional facts were elicited.
From 1952 until 1955, he had had episodes of shak-
ing chills, drowsiness, diffuse abdominal cramps
and constipation. In 1955, he had been treated for
amebiasis, and the symptoms had abated. The
symptoms had recurred in 1956, and the same
doctor had found an enlarged liver and had treat-
ed him for amebic hepatitis, with subsequent relief
of symptoms. He had never had diarrhea, but in
1947 on a trip to Mexico, his wife had had diarrhea.

In 1956, too, he had complained of drowsiness,
lack of energy and coughing. His protein-bound
iodine had been 2.2 micrograms per cent. Treat-
ment with thyroid, three grains daily for one year,
had improved his symptoms, and his protein-bound
iodine later had been 4 micrograms per cent. In
February, 1960, he had had a persistent cough and
a postnasal drip. Eosinophils had been found in a
nasal smear, and the symptoms had abated on
chlortrimeton therapy.

The family history was significant only in that
the patient’s mother had died of uremic poisoning
and ulcers.

Examination here revealed a blood pressure of
195/100 mm. Hg, a pulse of 60, a respiratory rate of
20 and a temperature of 98.6° F. The patient was
alert and looked healthy. The eyegrounds showed
a trace of arteriovenous nicking. The nasal mucosa
was hyperemic and edematous. The thyroid lobes
were not enlarged, but the isthmus was palpable
and firm. No abdominal masses, tenderness or
bruits were found. The prostate was flat and with-
out nodules. The right popliteal pulsation was
weaker than the left. There was a loss of hair over
the feet and the lower one-third of the calves. The
skin was dry, and the nails were brittle.

The basal metabolic rate was -29; the protein-
bound iodine was 5.8 micrograms per cent (but
only three weeks following intravenous pyelog-
raphy) ; the cholesterol was 242 mg. per cent; the
albumin-globulin ratio was 2. 7/3. 2 Gm.; the lupus
erythematosus preparation was negative; the blood
urea nitrogen was 80 mg. per cent; and the creati-
nine was 10.5 mg. per cent.

On the third hospital day, ureteral catheters
were easily passed to each kidney. On the right, 43
ml. of clear residual urine was present, and on the
left there was 86 ml. of clear urine. The bladder
was inflamed, but the culture of the urine was
negative. Ureteral catheter drainage brought the
blood urea nitrogen down to 33 mg. per cent and
the creatinine to 2.6 mg. per cent, but by the tenth
hospital day the patient began to have a fever of
102° F. The blood cultures were negative.

On the fourteenth hospital day, an operation was
performed. The ureters were obstructed by an
inoperable mass that could not be removed, though
the ureters were freed from this mass, and bilater-
al nephrostomies were performed. A large amount
of pus was present in the left kidney. Postoper-
atively, there was difficulty with his fluid balance
because of acidosis, but with fluid therapy he did
well until the twenty-first hospital day. Most of
his urinary output was from the left kidney, but
in spite of good urinary output, his blood urea
nitrogen rose to 135 mg. per cent on the twenty-
first hospital day. He became anuric on the twenty-
second hospital day, was afebrile, went into shock,
and died at 8:45 p.m.

217

218

Journal of Iowa Medical Society

April, 1962

SUMMARY OF CLINICAL DISCUSSION

Dr. Bernard J. Begley, Urology: Beginning to-
day’s discussion, Mr. William Dougherty will speak
for the Junior Class.

Mr. William J. Dougherty , junior ward clerk:
The presentation is that of a 67-year-old Iowa
farmer who had been in relatively good health
until 1952, when he developed abdominal com-
plaints that were intermittent until 1955, at which
time he was treated by his physician for amebiasis
and the symptoms cleared. He returned to his doc-
tor in 1956, that time with a liver involvement, and
again was successfully treated. Hypothyroidism
was diagnosed in him late in 1956, and his symp-
toms cleared with treatment with thyroid for one
year. Thereafter he was relatively asymptomatic,
according to the history, until July, 1960, when he
began noticing dizziness, drowsiness and lack of
energy. He was hospitalized on August 1, 1960,
after noting hematuria on two occasions. He
showed improvement, although he lost 14 lbs. be-
fore his admission here on August 24, 1960.

The results of the physical examination and the
laboratory findings have been outlined in the pro-
tocol. In addition, his blood and urine studies here
were negative. On the tenth hospital day, the
white blood cell count had risen to 17,700/cu. mm.,
with a differential of 17 bands and 76 segmented
polymorphonuclear leukocytes. A chest film taken
at that time indicated that the lung fields were
clear and that there was left ventricular hyper-
trophy.

We feel that this man had definite signs of hypo-
thyroidism, as indicated by his decrease in energy,
cold intolerance, skin and nail changes, a rather
slow pulse rate, a low basal metabolic rate and
the report, though possibly erroneous, that he had
improved with thyroid medication between 1956
and 1957. That the protein-bound iodine was with-
in the normal range is explained by the fact that
the patient’s blood urea nitrogen was elevated. The
fact that the cholesterol was within normal limits
does bother us just a bit, we admit. In addition,
we think that there had been chronic liver dam-
age, on the basis of the history of amebiasis given
in the protocol. We feel that this explains the in-
version of the albumin-globulin ratio, though there
can have been a chronic wasting disease or a
carcinoma. The obvious problem in differential
diagnosis in this case is the inoperable mass that
was found on surgery.

The passage of catheters and the discovery of 43
and 86 ml. of urine on the right and left sides, re-
spectively, indicates to us that there was obvious-
ly a mild hydronephrosis. We understand that this
was confirmed by a retrograde pyelogram made at
that time.

Congenital abnormalities, we think, are ruled
out by the successful passage of catheters plus the
fact that the patient gave no history pertaining to
the urinary tract before his entrance into this

hospital. We feel that inflammation was the cause
of his rise of temperature on the tenth hospital
day, but also that it had not been a reason for his
entering complaint. The possibility of stones in
the ureters, with fibrosis of the surrounding areas,
has been ruled out by the finding of an inoperable
mass. It is further discredited by the negative ret-
rograde pyelogram, by the fact that the ureteral
catheters were passed easily, and by the fact that
on cystoscopic examination, the ureteral orifices
were evidently normal.

The final possibilities for obstruction of the
renal pelvis or the ureters are tumors of the pel-
vis, the ureter, the kidney or the surrounding ret-
roperitoneal areas. Papillary tumors of the bladder
are ruled out by the negative cystoscopic examina-
tion. Infiltrative tumors of the bladder, however,
sometimes present with edema and hyperemia of
the bladder mucosa, and these to an inexperienced
person could represent cystitis. We feel that the
lack of distortion of the bladder and, again, the
fact that the catheters were passed easily justify
ruling out this possibility too. According to Dr.
Begley, a rectal examination made at this time was
reported in the history as having been negative for
masses or tenderness, thus probably ruling out a
pelvic neoplasm.

This man’s history of amebiasis leads us to a
couple of considerations. First of all, there may
have been an ameboma, a chronic granulomatous
tumor in the rectosigmoid area, with compression
of the ureters. Second, there is a possibility of pel-
vic abscess on the basis of a subclinical rupture of
the gut. These two possibilities, however, are ruled
out by (1) the negative gastrointestinal series that
was performed in another institution, (2) the lack
of rectal or abdominal tenderness, (3) the lack of
signs of bowel obstruction and (4) the absence of
systemic signs of an abscess.

Aneurysm of the abdominal aorta has been re-
ported as a cause of bilateral ureteral obstruction.
This can occur either by direct compression or by
extravasation of blood into the retroperitoneal
area, with organization, fibrosis and contracture
involving the ureters in consequence of their close
proximity to the aorta in this region. No palpable
mass was found and no bruits were heard, but the
patient was 5 ft. 8 in. tall and weighed 180 lbs.,
so a finding such as this could possibly be missed
on physical examination. We admit that this lesion
is rather rare, but in a man of the patient’s age we
don’t feel that it can be ruled out.

Secondary carcinomas are the commonest neo-
plasm of the ureter. These are often essentially
asymptomatic until the manifestations of uremia
make them evident. In the male, carcinoma of the
rectosigmoid, bladder and prostate are the most
likely primary sites, and in this case there are no
indications either on history or on physical exam-
ination that there was a primary neoplasm in any
of these locations. Primary carcinomas of the renal
pelves and ureters are classically accompanied by

Vol. LII, No. 4

Journal of Iowa Medical Society

219

hematuria, a mass in the flank and flank pain. In
this patient, only hematuria was present, but as is
classically the case, it was painless and intermit-
tent. Very few bilateral renal neoplasms have been
reported in the literature, but regional retroperi-
toneal metastasis or extension through the renal
veins across the midline could explain the fact
that both ureters were involved.

Our final possibility for bilateral obstruction of
the ureters, with resulting hydronephrosis and
pyelonephritis, is a primary retroperitoneal tumor.
A review of the literature and of cases in this
hospital between 1925 and 1946 was reported by
Donnelly in 1946. According to that report, the
chief and/or entering complaint was often vague
abdominal pain, constipation and progressive loss
of strength and weight. Often, an abdominal mass
was found in these cases. Again we believe that
this patient’s physical dimensions could have
masked the presence of such a mass. Dr. Donnelly
does state that involvement of both ureters was
noted in two of these cases, and that this diagnosis
is often made by the urologist following retrograde
pyelography, because of distortion of the ureter or
displacement of the kidneys. These changes were
indefinite or absent in the case that we are con-
sidering. The age of this patient, as compared with
the median age of 43 years, might possibly rule
against this tumor.

Of the four final categories — i.e., abdominal
aneurysm, primary or secondary carcinomas of
the renal pelves or ureters, and primary retro-
peritoneal tumor, we choose the last as our pro-
visional diagnosis. The patient’s condition resulted
in hydronephrosis and pyelonephritis. We feel that
hypothyroidism and diffuse liver damage as a re-
sult of amebiasis are to be postulated as coexisting
pathologic conditions. We believe that the terminal
event resulted from uremia, with severe fluid and
electrolyte imbalance plus, possibly, a compromise
of the renal blood supply by the mass, and result-
ant acute renal failure.

Dr. Begley: Thank you, Mr. Dougherty. Your
discussion was a fine one, and I think you’ve done
a good job, first, in discarding the false clues, sec-
ond in getting down to the fact that the patient
had bilateral ureteral obstruction, and finally in
attempting to determine the exact cause.

Dr. Rubin H. Flocks, Urology: I think that the
student’s discussion was an excellent one, par-
ticularly since he didn’t have an opportunity to see
the x-ray films, which give quite a great deal of
information.

The essential thing, as has been emphasized, is
the renal insufficiency on the basis of ureteral ob-
struction. The question is: “What can possibly
have been the reason for this ureteral obstruc-
tion?” Many of the possible explanations have
been outlined very well, but if we go back to the
x-ray films, there are certain points in them that I
should like to emphasize. As has been said, the
fact that the renal catheters went up very easily is

an extremely important point. On the right, the
x-rays show a dilation of the kidney pelvis and
reveal that this kidney was small, and showed a
tremendous amount of clubbing of the calyces and
a tremendous amount of renal destruction. On the
left the x-rays show similar changes, but with
hypertrophy of the renal obstructions and less
marked changes in the calyces. Now this is ex-
tremely important from the point of view of the
patient’s history. It is very likely that he hadn’t
had amebiasis, but that his problem back in 1952-
1955 (with vague abdominal pain, chills, fever and
constant constipation) may well have been associ-
ated with this lesion that was producing obstruc-
tion, more marked on the right side at that time,
and damaging that kidney over a long period of
time. Thus, the chances are very good that changes
have not been found at postmortem indicating
amebiasis in the liver. Actually, it is most likely
that the right-sided difficulty and the general ill-
ness that he had in 1952-1955 came from a lesion
that was producing obstruction to the ureters.

If my theory is correct, only the right side was
involved back in 1952-1955. Finally, the left side
became involved, and the patient became severely
uremic. He had a creatinine of 10 mg. per cent and
a blood urea nitrogen of 80 mg. per cent, and this
is frequently associated with a dry skin and the
other changes usually found with hypothyroidism.
At any rate, there is no question that the patient’s
right kidney had been damaged over a much long-
er time than his left.

Now, what are the lesions that produce obstruc-
tion to both ureters, perhaps starting on the right
side first, then involving the left side and finally
producing complete obstruction, but at the same
time permit ureteral catheters to be introduced
easily? In this set of pyelograms, one sees a hydro-
ureter and a hydronephrosis, with no evidence of
any congenital obstruction and with ureters that
are pointed inward rather than outward. What
lesion, though rare, will most frequently produce
this set of circumstances?

There are many causes of intrinsic ureteral ob-
struction, both congenital and acquired. None of
these common conditions fit this situation. There is
no evidence of a congenital situation from the
pyelogram, and the acquired lesions would pro-
duce difficulty in passing a ureteral catheter.

Of the extrinsic lesions, very few are bilateral.
The bilateral ones are the congenital extra-urinary
tract obstructions, but there is no evidence of them
here. The acquired lesions are, primarily, (1)
diverticulosis of the colon with chronic abscess
formation in the pelvis — usually associated with
marked difficulty in passing ureteral catheters —
(2) metastases or extensions of the various malig-
nant lesions such as carcinoma of the prostate,
carcinoma of the bladder or carcinoma of the colon
in the male, and (3) inflammation from the pros-
tate and seminal vesicles. Bladder diverticulum is
a cause of unilateral obstruction. Retroperitoneal

220

Journal of Iowa Medical Society

April, 1962

neoplasm, like malignant lymphoma and metas-
tasis from carcinoma of the testis, will push the
ureters outward and anteriorly, instead of keep-
ing them medial or even seeming to pull them
medially. Endometriosis will obstruct the ureter,
usually unilaterally and down low in the kidney
pelvis. Aneurysm of the abdominal aorta will pro-
duce obstruction when a ureteral catheter is
passed, and practically never starts on the right
side and then extends over to the left side. There
seems to be evidence that the obstruction on the
right side in this patient had been present for a
long period of time.

Thus we are left with one condition that seems
to fit everything — periureteritis plastica or retro-
peritoneal fibrosis, a chronic inflammatory lesion
pretty well limited to the fascia of Gerota or the
so-called “urinary tract fascia propria.” The fascia,
in this condition, shows a great many collagen
changes and in some respects looks like regional
ileitis. Clinically, this condition fits the patient’s
picture very well, for it starts on one side, finally
extends over to the other side, is long-standing,
fits with the x-ray pictures, and permits the easy
passage of ureteral catheters.

Assuming that this condition was found at the
time of operation, we can assume that a nephros-
tomy was carried out bilaterally to sidetrack the
obstruction. Apparently the patient did well for
about seven or eight days following that operation,
but then something happened so that he became
severely anuric and died within 24 hours. The
best possibility, I believe, is that the patient was
living on the left kidney and that the left ureteros-
tomy tube became plugged, or something of that
sort. Attempts to solve that difficulty must have
spread infection into that left kidney, producing
an acute pyelonephritis, sepsis, shock and death.
I think that the immediate cause of death was this
situation that I have last described.

Dr. Begley: The patient was in difficulty 24
hours prior to his death. The left nephrostomy
tube was not draining well and had to be replaced.
After ureteral catheter drainage and after the
pyelograms had been obtained, observation of the
medial deviation of the ureter, with hydronephro-
sis and hydroureter above it, led us to consider
two possibilities. We thought his problem might
be either periureteritis plastica or non-specific
retroperitoneal fibrosis, and also because there
was some calcification at the lower end of the
aorta on the lateral film, Dr. Lawrence saw the
patient and felt that he did have an aortic aneu-
rysm. His opinion was that it probably had not
leaked and was not associated with the present
illness, but because of this possibility Dr. Law-
rence assisted at the patient’s operation.

Dr. Jack M. Layton, Pathology : At autopsy, the
most striking findings were related to the retro-
peritoneal tissues and the urinary tract. A fibrous
mass lay in the retroperitoneal tissues over the
promontory of the sacrum, and extended laterally
to envelop the ureters. The upward extension was

in the region of the renal pelves, and the down-
ward extension was to the upper border of the
bony pelvis. The fibrous mass enveloped the retro-
peritoneal structures but did not invade them.

The ureters pursued an intraperitoneal course
from the renal pelvis to the rim of the bony pelvis,
the peritoneal incision having been sutured be-
neath them. They had been freed from the fibrous
mass, mobilized into the peritoneal cavity, and
then sutured beneath the peritoneum. There was
no evidence that the peritoneum was involved in
this process, for it was a retroperitoneal process.

Microscopically, very dense, collagenous tissue
was admixed with adipose tissue in varying
amounts, and in the areas where the surgical op-
eration had been performed, there were acute
cellulitis and necrosis secondary to the operative
procedure.

The right kidney weighed 60 Gm., as against a
normal of about 150 Gm., and the left kidney
weighed 385 Gm. The former disclosed chronic
atrophic pyelonephritis, and the latter acute and
chronic pyelonephritis. Bilateral nephrostomy
wounds to the flanks were present, and there was
a dehiscence of the left flank incision.

In the urinary bladder, there were superficial
ulcers and a mild trigonitis.

Atherosclerosis and its complications were pres-
ent in the vascular system. An aneurysm with
mural thrombosis was present in the terminal ab-
dominal aorta and the common iliac arteries, and
atherosclerotic plaques, with ulceration and mural
thromboses, were present throughout the aorta.
At a point one centimeter from the origin of the
left main coronary artery, an atherosclerotic
plaque occluded about 80 per cent of the lumen,
but distal to that point the coronary artery was
not involved. The right coronary artery showed no
particular atherosclerosis.

The heart was enlarged, weighing 530 Gm., and
the left ventricle was enlarged predominantly.

Although the gallbladder was enlarged and dis-
tended with bile, no obstruction was found in the
biliary system.

Mild, subacute fat necrosis was found in the pan-
creas. The liver displayed fatty metamorphosis of
moderate degree and pericholangitis, but there
was no evidence remaining to indicate amebiasis.

Although the thyroid gland appeared normal in
size, microscopically it displayed moderately se-
vere atrophy and fibrosis, with lymphocytic infil-
trates in the gland. Some old, healed tubercules
were present in the hilar lymph nodes, and hypo-
static pneumonia was an agonal feature.

This patient’s case was one classifiable as so-
called idiopathic retroperitoneal fibrosis, periure-
teritis plastica, periureteritis obliterans, periure-
teric fibrosis, or whatever else you may choose to
call the disease. He had had pyelonephritis some-
time earlier, with resultant extensive atrophy of
the kidney — chronic atrophic pyelonephritis. Ure-
teral obstruction was produced as the ureters were

Vol. LII, No. 4

Journal of Iowa Medical Society

221

progressively encased in the fibrous proliferations
that interfered with the peristaltic activity of the
ureters and interfered with the transport of urine.
There was secondary pyelonephritis again in the
obstructed kidney. The immediate cause of death
was sepsis following the difficulties with the acute-
ly infected kidney.

The students’ diagnosis was not far off, in a
sense, for the type of lesion they described — retro-
peritoneal malignant neoplasm — could be bilateral,
could produce the obstruction and could produce
ureteral displacement. One might very strongly
consider malignant lymphoma, Hodgkin’s type, or
retroperitoneal sarcoma as producing a somewhat
similar lesion, but the ureteral lesion would be
very important in the differential diagnosis.

The cause of this condition is completely ob-
scure. Many hypotheses have been advanced. It
is a disorder that has been said to be confined to
Gerota’s fascia. Dr. John Hutch, a classmate of
mine and a former resident in urology here, has
postulated that this should really be looked upon
as a fasciitis. Could you tell us about Gerota’s
fascia, Dr. Flocks, and about whether or not the
course of the disease is consistent with Dr. Hutch’s
view?

Dr. Flocks: Most of the cases of bilateral ob-
struction of the kind described are ones in which
the lesion extends across the midline and involves
the great vessels. Ordinarily, we feel that the
fascia of Gerota, or the urogenital fascia propria,
does not extend across the midline, and the vessels
as they come to the kidney and to the ureters have
to enter the fascia of Gerota. Thus, in a sense, our
concept of the normal physiology does not fit with
Dr. Hutch’s idea.

Ormond, who described the first successful treat-
ment of such cases in this country, back in 1948,
has reviewed the matter completely in j.a.m.a. for
November 19, I960.* Regarding the etiology, he
says:

“The impression is given of a slowly progressive
inflammation originating about the great vessels
and spreading laterally, enveloping, but rarely
invading, the retroperitoneal structures as it
spreads, healing and contracting even as it spreads.
The retroperitoneal structures, the ureters, are
particularly vulnerable. Arteries and nerves are
sturdy structures, not nearly as compressible as
veins and ureters. Compression of veins, if not too
rapid, is compensated for by the collateral circula-
tion, and there need be no evidence of such com-
pression, but there is no compensatory drainage
of urine, and compression of the ureters is bound
to affect the kidney. Hence, in all the cases re-
ported, its presence has been brought to light by
its effect on the kidneys.”

Now the areas that have been implicated have
been, primarily, the periaortic lymph nodes. The
lymph glands, actually, had been mentioned only

* Ormond, J. K.: Idiopathic retroperitoneal fibrosis, j.a.m.a.,
174:1561-1568, (Nov. 19) 1960.

three times in the 64 proved cases that Dr. Ormond
reported.

Dr. Layton: I might say that in the current case
they do not appear to have been involved.

Dr. Flocks: Organizing hematoma due to hemor-
rhage, trauma or other conditions has been ad-
vanced as a cause. Hemorrhage with hematoma
formation can occur anywhere in the body, and
a great deal is known about the fate of that sort
of phenomena. Hematomas may be absorbed. If
infected, they may become cystic — i.e., surrounded
by a fibrous capsule — and they have a tendency
towards calcification. Their pattern does not re-
semble that of the fibrosis that we are considering
here. It has been suggested as being, perhaps,
significant that none of these cases occurred be-
fore the antibiotic era. Perhaps infections in these
patients have been only partially controlled by
antibiotics, and these lesions may be the result.

Ileitis has been mentioned as a possible cause
because it is often difficult to detect and could
easily be overlooked. It certainly could be over-
looked in retroperitoneal operations, but there
have been a large number of transperitoneal op-
erations in which it was not found, nor was it
found in any of the autopsies. Thus, although
ileitis undoubtedly can cause periureteral fibrosis,
though there are several reports indicating that
ileitis has caused it, and though there are several
reports showing a relationship between ileitis and
ureteral obstruction, we can definitely rule out
ileitis as a cause of the idiopathic fibrosis that we
are considering in this patient. Frank Hinman,
Jr., has recently redirected attention to the phe-
nomenon connected with temporary ureteral ob-
struction in which diffuse extravasation of the
urine occurs into the urogenital fascia propria,
and he feels that in some instances it may be the
cause of the condition we are discussing.

Riedel’s struma, otherwise known as chronic
ligneous thyroiditis, is also a mystery, and in this
particular case there was a fibrosis, at least, in
portions of the thyroid. Whether there is a con-
nection in this instance, we do not know.

In Dupuytren’s contracture of the palmar fascia,
there is a thick, confluent mass of fibrous tissue
with foci of lymphocytic infiltration in the palm of
the hand. This may be a related situation. At any
rate, there are many theories, but no one really
knows what causes this chronic lesion.

Dr. Layton: Do you know anything about the
patient’s blood pressure in 1960?

Dr. Begley: You are referring to the patient’s
first admission?

Dr. Layton: Yes, at his first admission. I am
wondering whether he developed a “Goldblatt
kidney.”

Dr. Begley: There is no notation in the history
regarding his previous blood pressure determina-
tions.

I think that the x-ray taken when the nephrosto-
my tube was replaced on the day prior to the pa-

blood pressure approaches normal
more readily, more safely.... simply

(hydroflumethiazide, reserpine, protoveratrine A-antihypertensive formulation)

Early, efficient reduction of blood pressure. Only Salutensin combines
the advantages of protoveratrine A (“the most physiologic, hemody-
namic reversal of hypertension”1) with the basic benefits of thiazide-
rauwolfia therapy. The potentiating/additive effects of these agents2"8
provide increased antihypertensive control at dosage levels which
reduce the incidence and severity of unwanted effects.

Supplied: Bottles of 60 scored tablets.

References: 1. Fries, E. D.: In Hypertension, ed. by J. H. Moyer, Saunders, Phila., 1959 p. 123.
2. Fries, E. D.: South M. J. 51:1281 (Oct.) 1958. 3. Finnerty, F. A. and Buchholz, J. H.: GP 17:95
(Feb.) 1958. 4. Gill, R. J., et al.: Am. Pract. & Digest Treat. 11:1007 (Dec.) 1960. 5. Brest, A. N.
and Moyer, J. H.: J. South Carolina M. A. 56:171 (May) 1960. 6. Wilkins R. W.: Postgrad. Med.
26:59 (July) 1959. 7. Gifford, R. W., Jr.: Read at the Hahnemann Symp. on Hypertension, Phila.
Dec. 8 to 13, 1958. 8. Fries, E. D., et al.: J. A. M. A. 166:137 (Jan. 11) 1958. 9. Ford, R. V. and
Nickel!, J.: Ant. Med. &. Clin. Ther. 6:461, 1959.

all the antihypertensive benefits of thiazide-
rauwolfia therapy plus the specific,
physiologic vasodilation of protoveratrine A

11 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS BY SERIAL ADDITION OF
THE INGREDIENTS IN SALUTENSIN IN A TEST CASE

(Adapted from Spiotta, E. J.: Report to Department of Clinical Investigation, Bristol Laboratories)

SALUTENSIN

Hg.

190

180

170

160

150

140

130

120

110

100

thiazide

-A.

thiazide

protoveratrine A

(thiazide
protoveratrine A
reserpine)

JAN. FEB. MARCH

12 19 27 3 10 17 24 2 9 17 23 30

3Vi WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS USING SALUTENSIN FROM
THE START OF THERAPY IN A “DOUBLE BLIND” CROSSOVER STUDY

Mean Blood Pressures-Systolic (S) and Diastolic (D)

mm
Hg.

190
180
170
160
150
140
130
120
110
100
90
80
70
60
50

BRISTOL LABORATORIES/Div.of Bristol-Myers Co., Syracuse, N.Y.

Placebo Followed by Salutensin
(22 patients)

Salutensin Followed by Placebo
(23 patients)

Placebo Salutensin

Before After Before After

Salutensin Placebo

Before After Before After

224

Journal of Iowa Medical Society

April, 1962

tient’s death is an interesting one. It shows the
nephrostomy tube entering the left kidney. The
contrast medium was in the kidney and, in addi-
tion, there appeared to be some extravasation of
the contrast medium. It also shows the ureter that
had been placed in the peritoneal cavity to get it
away from the mass, and its course was the typical
one for such a ureter following surgical therapy.
The extravasation there is the important thing.
The patient had pulled his nephrostomy tube out.
We don’t know how he pulled it out, but it didn’t
drain. Although we were able to replace it, the
instrumental trauma probably led to a bacteremic
episode, and in this azotemic and severely debili-
tated man, there was no response as regards ele-
vation of temperature and there was no response
as regards elevation of white blood cell count. The
first real response was that of vascular collapse.

Dr. Flocks: I’d like to mention the therapy of
this particular situation. We’ve actually had four
cases, and the therapy cited in the literature is
borne out by our own experience.

In our first case, we didn’t know about Ormond’s
description. The patient developed difficulty on the
right side, with the typical findings only on the
right side. I explored him and found essentially
what was found in the man whom we have been
discussing. I made biopsies of the retroperitoneal
mass, which I thought was a retroperitoneal sar-
coma obstructing the right kidney, and the pathol-
ogists’ report on the frozen section was “fibrosis,
fibrous tissue and no tumor.” Because I didn’t be-
lieve the report on the frozen section, I took out
more pieces and proceeded to remove the ureter
and kidney so that the tumor could be treated very
intensively with irradiation therapy. The pathol-
ogists still reported “fibrosis.” We then went to
the literature, and found the description of this
particular disease.

About six or eight months later, the same pa-
tient came back. The mass had extended over to
his left side, producing an obstruction, and we
then followed Dr. Ormond’s surgical recommenda-
tion, which is primarily to transplant the ureter
intraperitoneally, as you can see in this postop-
erative film. Here, on pyelography, the ureter
seems to be displaced laterally to a marked degree,
but the obstruction has been done away with.
It has been about nine years since that patient’s
last operation, and he is perfectly well.

The second patient was referred to me by Dr.
Theilen. She had been treated over a period of
several years for chronic urinary-tract infection,
with secondary anemia and all the sequelae of
chronic infection. Finally, she was sent here for
further treatment of her chronic pyelonephritis.
We found the typical changes bilaterally. We were
able satisfactorily to transplant both ureters in-
traperitoneally, to cure the infection completely,
and to achieve an altogether excellent result.

Now, in the meantime there has been a great
deal of discussion in the literature regarding the

treatment of these patients with steroids, and we
tried them on the next of our cases. We did not
obtain any regression of the lesion through the use
of steroids, and that is the usual finding. The only
exception has been one of two cases reported from
one institution. The treatment for this condition,
then, is a surgical one — to sidetrack the urine by
transplanting the ureter intraperitoneally.

In the case that we have been discussing this
afternoon, the patient was very sick, and diver-
sion of the urinary stream was thought necessary.
Apparently that procedure was carried out, in
addition to transplanting the ureter. The question
arises in my mind whether it wouldn’t have been
wiser simply to do a bilateral nephrostomy and
get the patient into better shape before doing the
extensive transplantation of the ureter.

So much, then, for the therapy. There has been
some discussion of x-ray treatment of this chronic
fibrosing lesion, but no evidence has been discov-
ered that in itself it has halted the lesion. Dr.
Ormond has raised a question as to what happens
to the retroperitoneal lesion in patients who have
been subjected to the surgery that he recom-
mends— whether the urinary obstruction has been
permanently relieved. For example, it would be
interesting to reexplore our first patient to see
what has happened to his lesion.

Dr. Begley: The definitive diagnosis of this con-
dition, then, is arrived at only by the pathologist.
The suggestive findings are hydronephrosis, hy-
droureter, extrinsic compression of the ureter and
medial deviation of the ureter. These signs can be
ascertained in patients only by means of pye-
lography.

Dr. Henry E. Hamilton, Internal Medicine: Dr.
Layton, is the mucopolysaccharide content of this
material similar to that found in pretibial myxede-
ma?

Dr. Layton: No. I’ve looked at some of those
pretibial myxedemas for Dr. Hamilton, but this
appears to be more densely collagenous and not
so basophilic and swollen. But I haven’t done the
definitive stains. My guess is that it probably is
not the same.

Dr. Robert Hickey, Surgery: Perhaps Dr. Lay-
ton will answer a question for me. At a recent
surgical meeting in Iowa City, Dr. Hertlizka, of
Mason City, presented a series of patients whom
he and his associates had encountered. The ther-
apy that was carried out was very similar to the
one that this patient received, but he made the
point that in years gone by, several patients had
been found to have retroperitoneal sarcomas, and
after a decompressing operation for the urinary
tract, they survived for unusually long periods of
time. Can it be that some of the cases formerly
diagnosed as fibrosarcomas in the retroperitoneal
area were actually cases of this lesion that we
have been discussing today?

Dr. Layton: There is nothing like time as a test
for the diagnosis of malignancy. If a patient lives

Vol. LII, No. 4

Journal of Iowa Medical Society

225

for 35 years after having had a lesion diagnosed
as fibrosarcoma, I would want to look at the old
sections again.

Dr. Flocks: The following is a quotation from
an editorial in lancet: “Many a clinical reputation
lies behind the peritoneum. In this hinterland of
straggling mesenchyme with its vascular and nerv-
ous plexuses, its weird embryonic rests, its sha-
dowy fascial boundaries, the clinician is often left
with only his plan and his diagnostic first prin-
ciples to aid him. Nonspecific periureteric fibrosis
is likely to tax them both.

“At an early stage the symptoms usually point
to a growing retroperitoneal lesion, but this lim-
ited diagnosis is rarely made. Retroperitoneal pain
can be severe and persistent enough to drive the
most phlegmatic patient to distraction, but when
there are no abdominal findings, his complaint is
likely to be received with incredulity.”

Dr. Begley: I’d like to thank the discussants, Dr.
Flocks and Mr. Dougherty, for their excellent
discussions.

SUMMARY OF NECROPSY FINDINGS

Idiopathic retroperitoneal fibrosis (periureteritis
plastica), postoperative
Nephrostomy, bilateral

Intraperitoneal ureteral transplantation, bilateral
Acute and chronic pyelonephritis, bilateral
Atherosclerosis, generalized

Aneurysm, abdominal aorta and common iliac
arteries

STUDENTS' DIAGNOSES

Primary retroperitoneal tumor

Hypothyroidism

Liver damage from amebiasis

DISCUSSANT'S DIAGNOSES

Periureteritis plastica
Chronic and acute pyelonephritis

CLINICAL DIAGNOSES

Periureteritis plastica
Abdominal aortic aneurysm.

Dr. Lee Forrest Hill, Des Moines pediatrician and vice president of the Iowa Medical Society, is shown (left) after receiving
a distinguished service award on behalf of the Society. The award, presented by the Iowa Chapter Arthritis and Rheumatism
Foundation at its annual meeting, January 30, in the Hotel Fort Des Moines, was given to the Society for the outstanding
service Iowa physicians rendered to arthritis sufferers during 1961. Mr. C. William Schneider, the Chapter's executive direc-
tor (center) made the presentation. Dr. William D. Paul, a professor of physical medicine and rehabilitation at SUI and the
Chapter's medical chairman, is seated at the right.

Coming Meetings

Apr. 6-8

Apr. 13-14
May 13-16

Apr. 1-6

Apr. 2-4
Apr. 2-4
Apr. 2-4
Apr. 2-5
Apr. 2-6
Apr. 2-6

Apr. 4-6
Apr. 4-7

Apr. 5-7
Apr. 5-7

Apr. 5-7

Apr. 6-7
Apr. 6-8

Apr. 9-11

Apr. 9-12
Apr. 9-12

Apr. 9-13

Apr. 10-12
Apr. 12-14

Apr. 12-14
April 12-14

Apr. 13-14
Apr. 13-14
Apr. 13-14

Apr. 13-15
Apr. 15-18
Apr. 15-21
Apr. 16-18
Apr. 16-18

IOWA

Third Midwestern Sectional Meeting of the
Biological Photographic Association. Down-
towner Motor Inn. Des Moines
Pediatric Conference. Raymond Blank Me-
morial Hospital, Des Moines
Annual Meeting of the Iowa Medical Society.
Veterans Auditorium and Savery Hotel, Des
Moines

CONTINENTAL U. S.

American College of Allergists Graduate In-
structional Course and 18th Annual Congress.
Hotel Radisson, Minneapolis
American Radium Society. Waldorf-Astoria
Hotel, New York City

Thirty-fifth Annual Spring Congress in
Ophthalmology and Otolaryngology and Allied
Specialties (Gill Memorial Eye, Ear and
Throat Hospital). Patrick Henry Hotel, Ro-
anoke, Virginia

Otorhinolaryngology. University of Kansas
School of Medicine, Kansas City, Kansas
U.S.P.H.S. Clinical Society. Clinical Center,
National Institutes of Health, Bethesda, Mary-
land

Water, Salts and Steroids. University of
California, San Francisco

Current Concepts of the Physiology of the
Endocrines, Electrolytes and the Kidney.
(American College of Physicians in conjunc-
tion with the American Physiologic Society),
University of Pennsylvania, Philadelphia
Clinical Symposium: Surgery of the Newborn.
Cook County Graduate School of Medicine,
Chicago

Association of Clinical Scientists. Sheraton-
Chicago Hotel, Chicago

Annual Meeting of the American Society of
Internal Medicine. Benjamin Franklin Hotel,
Philadelphia

Anesthesiology. University of Kansas School
of Medicine, Kansas City, Kansas
Aerospace Medical Association. Atlantic City
Fourteenth Annual Scientific Assembly of the
American Academy of General Practice. Las
Vegas Convention Center, Las Vegas
Forty-Third Annual Session of the American
College of Physicians. Convention Hall and
Bellevue-Stratford Hotel, Philadelphia
Industrial Medical Association. Pick-Congress
Hotel, Chicago

Otolaryngology for General Physicians. Center
for Continuation Study, University of Min-
nesota, Minneapolis

Highlights of Modern Ophthalmology. Presby-
terian Medical Center, San Francisco
Psychiatry in Hospitals (The Catholic Hos-
pital Association). Conrad Hilton Hotel, Chica-
go

American Society for Artificial Internal Or-
gans. Hotel Claridge, Atlantic City, N. J.
Symposium on the Knee. Harvard Medical
School, Boston

Review of Advances in Surgery for G.P.’s.
Stanford University School of Medicine, Palo
Alto, California

American Association for Cancer Research.
Chalfonte-Haddon Hall, Atlantic City, N. J.
California Medical Association Annual Ses-
sion. Fairmont Hotel, San Francisco
American Society for Experimental Pathology.
Atlantic City, N. J.

American Association for Thoracic Surgery.
Chase-Park Plaza Hotel, St. Louis
Internal Medicine for Internists. Center for
Continuation Study, University of Minnesota,
Minneapolis

Apr. 16-20
Apr. 17

Apr. 22-24
Apr. 23-25
Apr. 23-25

Apr. 23-28

American Society of Biological Chemists, Inc.
Atlantic City, N. J.

Essential Anesthetic Equipment. University of
Kansas School of Medicine, Kansas City, Kan-
sas

Spring Session of the American Academy of
Pediatrics. Statler-Hilton Hotel, Los Angeles
Pan American Congress of Gastroenterology.
Hotel Roosevelt, New York City
Fifteenth Annual Spring Meeting, West Vir-
ginia Academy of Ophthalmology and Oto-
laryngology. Greenbrier Hotel, White Sulphur
Springs, West Virginia

American Academy of Neurology. Statler-Hil-
ton Hotel, New York City

April 23-May 4 Surgical Review for the General Surgeon
(U. S. Section of the International College of
Surgeons). Cook County Graduate School of
Medicine, Chicago

April 23-May 4 Diagnostic Radiology. Cook County Graduate
School of Medicine, Chicago

Apr. 24-25 American Society for Gastrointestinal Endos-
copy. Roosevelt Hotel, New York City
Apr. 25-28 American College Health Association. Chicago
Apr. 25-28 Sixth Postgraduate Course on Fractures and
Other Trauma (Chicago Committee on Trau-
ma of the American College of Surgeons).
John B. Murphy Memorial Auditorium, 50
East Erie Street, Chicago

Apr. 26-28 General Surgery. University of California,
San Francisco

Apr. 26-28

Apr. 26-28
Apr. 28
Apr. 29

Surgery for Surgeons. Center for Continua-
tion Study, University of Minnesota, Min-
neapolis

Clinical Symposium: The Problems of Aging.
Cook County Graduate School of Medicine,
Chicago

American Gastroenterological Association. Ho-
tel Roosevelt, New York City
American Society for Clinical Nutrition. Chal-
fonte Hotel, Atlantic City, N. J.

American Federation for Clinical Research.
Haddon Hall, Atlantic City, N. J.

Apr. 29-30 American Otological Society, Inc. Sheraton
Dallas Hotel, Dallas

Apr. 29-May 2 International Academy of Pathology and
American Association of Pathologists and Bac-
teriologists. Queen Elizabeth Hotel, Montreal,
Canada

Apr. 30-May 1 Society of Head and Neck Surgeons. Queen
Elizabeth Hotel, Montreal, Canada

Apr. 30-May 2 Kansas Medical Society. Town House Hotel,
Kansas City, Kansas

Apr. 30-May 2 Gynecology for General Physicians. Center
for Continuation Study, University of Min-
nesota, Minneapolis

Apr. 30-May 2 American Academy of Pediatrics (Spring
Meeting). Statler-Hilton, New York City

Apr. 30-May 3 Nebraska State Medical Association. Hotel
Cornhusker, Lincoln, Nebraska
Apr. 30-May 3 American Proctologic Society. Deauville Hotel,
Miami Beach

April 30-May 11 Obstetrics, General and Surgical. Cook Coun-
ty Graduate School of Medicine, Chicago
May 1-2 American Broncho-Esophagological Associa-

tion. Sheraton-Dallas Hotel, Dallas

May 1-3

May 1-5
May 3-5
May 3-5

May 4-5
May 4-6
May 4-7
May 5-9

May 6-10

American Laryngological, Rhinological and
Otological Society, Inc. Sheraton-Dallas Hotel,
Dallas

American Association on Mental Deficiency.
Statler Hotel, New York City
American Association for the History of
Medicine, Inc. Ambassador Hotel, Los Angeles
American Association for Cleft Palate Re-
habilitation. Netherland Hilton Hotel, Cincin-
nati

American Laryngological Association. Shera-
ton-Dallas Hotel, Dallas

Society of Biological Psychiatry. Royal York
Hotel, Toronto, Canada

American Psychoanalytic Association. Royal
York Hotel, Toronto, Canada
108th Annual Meeting of the North Carolina
Medical Society. William Neal Reynolds Coli-
seum (State College Campus). Sir Walter
Raleigh Hotel, Raleigh, N. C.

American Society for Microbiology. Muehle-
bach Hotel, Kansas City, Missouri

226

Vol. LII, No. 4

Journal of Iowa Medical Society

227

May 6-10
May 7-11
May 7-11
May 7-11
May 8-10
May 9-11

May 9-12
May 9-13
May 10-11
May 10-12
May 13-17
May 14-16

May 14-17

May 14-18
May 14-18

May 14-18

May 15

May 16-19

May 17-18
May 20-23

May 20-25
May 21-23

May 21-24
May 21-25

May 21-25
May 21-25
May 24-26
May 26
May 26-30
May 28-30

May 28-30
May 29-June 2
May 31-June 2

Apr. 8-29

Apr. 15-18
April 22-29

American Association of Plastic Surgeons.
Hotel Del Coronado, Coronado, California
American Psychiatric Association. Royal York
Hotel, Toronto, Canada

General Surgery. Cook County Graduate
School of Medicine, Chicago
Advances in Medicine. Cook County Grad-
uate School of Medicine, Chicago
Society for Pediatric Research. Traymore Ho-
tel, Atlantic City

American Association of Genito-Urinary
Surgeons. Skytop Lodge, Skytop, Pennsylva-
nia

American Thyroid Association. Roosevelt Ho-
tel, New Orleans

Student American Medical Association. May-
flower Hotel, Washington, D. C.

American Pediatric Society. Traymore Hotel,
Atlantic City

Ear, Nose and Throat. University of Califor-
nia, San Francisco

Annual Meeting of the Illinois State Medical
Society. Hotel Sherman, Chicago
Fundamental and Applied Aspects of Cardiol-
ogy (American College of Physicians). Wayne
State University College of Medicine, Detroit
American Urological Association. Bellevue-
Stratford Hotel, Philadelphia
Surgery. University of Kansas School of Med-
icine, Kansas City, Kansas
American Nurses’ Association. Detroit
Vaginal Approach to Pelvic Surgery. Cook
County Graduate School of Medicine, Chicago
Blood Vessel Surgery. Cook County Graduate
School of Medicine, Chicago
Rehabilitation in the Older Patient. University
of Kansas School of Medicine, Kansas City,
Kansas

Expanded Surgery of the Nasal Septum and
Closely Related Structures (American Rhi-
nologic Society). St. Michael Hospital, Mil-
waukee

Proctology. University of California, San
Francisco

57th Annual Meeting, American Thoracic
Society. Deauville and Carillon Hotels, Miami
Beach

National Tuberculosis Association. Deauville
Hotel, Miami Beach

109th Annual Meeting of the Minnesota State
Medical Association. Hotel Leamington and
the Minneapolis Auditorium, Minneapolis
Catholic Hospital Association Convention. Kiel
Auditorium, St. Louis

The Neurology of Diseases of Internal Med-
icine (American College of Physicians). Har-
vard Medical School, Boston
General Practice Review. Cook County Grad-
uate School of Medicine, Chicago
Breast and Thyroid Surgery. Cook County
Graduate School of Medicine, Chicago
Genetics. University of California, San Fran-
cisco

Inhalation Therapy. Stanford University
School of Medicine, Palo Alto, California
American Society of Maxillofacial Surgeons.
Montreal, Canada

Tenth Annual Western Cardiac Conference.
University of Colorado Medical Center, Den-
ver

American Ophthalmological Society. The
Homestead, Hot Springs, Virginia
American College of Cardiology. Denver Hil-
ton Hotel, Denver

American Gynecological Society (Members and
Invited Guests). The Homestead, Hot Springs,
Virginia

ABROAD

Bahamas Medical Conference, Nassau. Con-
tact: Mr. Irwin N. Wechsler, Executive Direc-
tor, P. O. Box 1454, Nassau, Bahamas
Asian Conference of Experts on Student
Health. Peradeniya, Ceylon. Write: World Uni-
versity Service, 13 rue Calvin, Geneva, Swit-
zerland

May

May-June

May 3-6
May 4-6

World Health Organization, Palais de Nations,
Geneva, Switzerland. Write: Secretary-Gen-
eral, World Health Organization, Palais de
Nations, Geneva

European Surgical Clinics Tour (Interna-
tional College of Surgeons). England, The
Netherlands, Germany, Italy, France, Switzer-
land. For Information Write: Secretariat, In-
ternational College of Surgeons, 1516 Lake
Shore Drive, Chicago 10

106th Annual Meeting of the Hawaii Medical
Association, Honolulu.

International Society of Ski Traumatology and
Winter Sports Medicine. Obergurgl, Tyrol,
Austria. Write: Professor Dr. Wolfgang Baum-
gartner, Chirurg. University Klinik, Innsbruck,
Austria

May 13-19 World Congress of Gastroenterology, Munich,
Germany. Write: Medizinische Universitats-
klinik, Krankenhausstrasse 12, Erlangen, Ger-
many

May 14-18 International Congress on Hormonal Steroids,

Milan, Italy. Professor L. Martini, Instituto de
Farmacologia e Terapia, 21 Via A. del Sarto,
Milan

May 15-19 Congress of the European Federation (Inter-

national College of Surgeons). Amsterdam,
The Netherlands

May 21-July 9 Medical Centers of Europe (University of
Southern California). Tuition: Part A. Lon-
don, Stockholm, Copenhagen and Paris (May
21-June 15) $250; Part B. Italy (June 16-30)
$150; Part C. Greece (June 30-July 9) $75.
For information write: Phil R. Manning,

M.D., Associate Dean, Postgraduate Division,
U.S.C. School of Medicine, 2025 Zonal Ave.,
Los Angeles 33

May 26-30 International Congress for Hygiene and Pre-
ventive Medicine. Vienna, Austria. Write:
Med. -Rat Dr. Ernst Musil, Mariahilferstrasse
177, Vienna 15

May 27-31 American Orthopaedic Association (Members).
Castle Harbor Hotel, Bermuda

July 1-4 International Conference on Oral Surgery.

Royal College, London. Write: D. C. Trexler,
Executive Secretary, American Society of Oral
Surgeons, 840 North Lake Shore Drive, Chica-
go 11

July 8-12 International Congress of Psychosomatic Med-

icine and Childbirth. Paris. Contact: Dr. L.
Chertok, 22 rue Legendre, Paris 17, France

June 16-21

July 30-
Aug. 13

Aug. 8-15

Sept. 5-8

Sept.

International Symposium on Enzymic Activity
in the Central Nervous System, Goteborg,
Sweden. Write: Dr. A. Lowenthal, Institut
Bunge, 59 rue Philippe Williot, Berchem-
Antwerp, Belgium

Fifth Annual Refresher Course (University
of Southern California). Royal Hawaiian
Hotel, Honolulu, and on S. S. Matsonia. Ad-
dress: Phil R. Manning, M.D., Associate Dean
Postgraduate Division, U.S.C. School of Med-
icine, 2025 Zonal Avenue, Los Angeles 33
International Fertility Association, 4th World
Congress, Hotel Copocabana, Rio de Janeiro.
Write: Dr. Maxwell Roland, Secretary, 109-23
71st Road, Forest Hills 75, New York
International Congress of Internal Medicine,
Munich, Germany. Write: Professor Dr. E.
Wollheim (President of Congress), Luitpold-
krankenhaus, Wurzburg, Germany
International Congress of Infectious Pathol-
ogy, Bucharest, Rumania. Write: Professor S.
Nicolau, Via Parigi, 7-Bucharest
Third International Conference on Alcohol
and Road Traffic, London. Write: Mr. J. D. J.
Havard, Secretary, Committee on Manage-
ment, British Medical Association House, Tavi-
stock Square, London

Oct. 7-13 World Congress of Cardiology, Medical Cen-

ter. Mexico City. Write: Dr. I. Costero, In-
stituto N. De Cardiologia, Avenida Cuauhte-
moc 300, Mexico 7, D. F.

Oct. American Society of Plastic and Reconstruc-

tive Surgery, Hawaiian Village Hotel, Hono-
lulu. Write: T. Ray Broadhent, M.D., Sec-
retary, 508 East South Temple, Salt Lake City
Nov. 11-16 World Medical Association. Vigyan Bhawan
Building, New Delhi, India. Write: Dr. Harry
S. Gear, 10 Columbus Circle, New York 19

Dec.

Feb. 20-24,
1963

International Congress of Medical Women's
International Association. Philippines. Write:
Dr. Rosita Rivera-Ramirez, Sta. Teresita Hos-
pital, 82 D. Tuazon, Quezon City, Philippines

Seventh International Congress on Diseases of
the Chest (American College of Chest Phy-
sicians). New Delhi, India

228

Journal of Iowa Medical Society

April, 1962

Doctor, How Is Your Biopsy Technic?

In an era of remarkable progress in the field of
surgery, it is surprising to find that careful atten-
tion is not always given to the technics of biopsy.

The problem has been emphasized by Hardy,
Griffin and Rodriguez in their biopsy manual: *
“Although the taking of the biopsy is commonly
considered a minor procedure, which it frequently
is, the importance of this step far transcends its
magnitude as an operative procedure, for upon
the accuracy of the biopsy may depend all subse-
quent management and even the patient's life. Yet
despite the acknowledged gravity of a dependable
biopsy in the diagnosis of many serious diseases,
this procedure is all too often executed in such a
manner as to afford disappointing if not tragic re-
sults.”

The following are some of the phenomena that
occasionally impede the pathologist in making his
evaluations:

The topper specimen — the inflammatory crust
which a timid operator has removed from a cu-
taneous lesion, and on which he fully expects to
be given a forthright pathologic diagnosis.

The marginal biopsy — a specimen that is all mar-
gin sans lesion.

The miniature biopsy — a fragile sliver of tissue
which has been obtained from a large lesion by
an operator who expects to have both frozen and
paraffin sections prepared from it.

The crushed lesion — a biopsy that has been
damaged by a clamp placed directly across the
very area to be examined.

The slashed specimen — a small piece of tissue in
which the surgeon has made various deep cuts in
order to satisfy his curiosity. He has thus distorted
the lesion, but he still expects the pathologist to
use it in evaluating the adequacy of the excision.

The wayward malignant melanoma — an unrecog-
nized malignant melanoma which has been put
into a container along with several benign pig-
mented skin lesions from various parts of the
body, none identified as to specific source.

Scrambled curettings — thoroughly shredded en-
dometrium, the result of excessive irregular or
rotary curettage.

The naked cone — a cervical cone from which

* Hardy, J. D., Griffin, J. C., Jr., and Rodriguez, J. A.:
biopsy manual. Philadelphia, W. B. Saunders Co., 1959.

practically all of the epithelium has been scraped
away during excision, despite the fact that the
purpose of the operative procedure was to obtain
that epithelium for examination.

The lost biopsy — a biopsy which has been left
on a sponge to be discarded by a complacent nurse
who has carefully safeguarded the appendix for
submission to the pathologist.

It may be stated categorically that the accuracy
of the pathologic diagnosis will not exceed the
adequacy of the biopsy. It thus would be well for
every biopsy surgeon, be he generalist or special-
ist, to become informed on the problems involved
in handling and processing specimens so that they
will yield satisfactory mounted microscopic sec-
tions amenable to diagnosis. He needs only to en-
vision himself as the pathologist receiving a speci-
men in order to recognize what needs to be done
as each biopsy procedure is planned.

Such a well oriented operator will:

Never fail to obtain a specimen of adequate
depth.

Never fail to sample a lesion adequately (to
the extent permitted by good surgical judgment).

Never crush, distort or otherwise damage a
lymph node.

Never place a clamp on an area that is to be
studied microscopically.

Never rub away with a sponge or scrape away
with a knife or place a clamp upon the epithe-
lium of a cervical cone.

Never distort a lesion after excision by cut-
ting across it through an area from which the
pathologist will need to take a block for process-
ing.

Always insist that biopsy specimens be placed
in clearly identified containers immediately after
removal.

Always give the pathologist enough informa-
tion to enable him to orient the specimen prop-
erly.

Always regard a request for examination of a
biopsy as a request for consultation, and pro-
vide his consultant with information on the
source of the lesion, the age of the patient, and
such clinical and operative findings as he would
want if he were the pathologist.

If the pathologist is to be a consultant, rather
than a super-technician, he must make contribu-
tions to accurate biopsy diagnosis transcending
the procedure of peering into a microscope. He
should maintain close communication with the
biopsy surgeon. On occasion, he should see the
patient prior to operation. By that means, he will
have knowledge of the diagnostic problems in-
volved in the particular case, and will have an op-
portunity to suggest what specimens ought to be
taken. He should not fail to inform a surgeon when
he is dissatisfied with a specimen, yet at the same
time he must fully understand the exigencies that
sometimes make the obtaining of a biopsy excep-
tionally difficult.

Vol. LII, No. 4

Journal of Iowa Medical Society

229

The pathologist should institute careful control
measures in his histology laboratory, and should
meet the challenge posed by the miniature biopsy
whenever necessary. Almost never should he re-
port that a specimen has been lost while being
processed, as a result of its having been too small.

The Case of the Misused Catheter

Not too long ago, an elderly patient came into
our office complaining of severe burning, fre-
quency and difficulty in urination. He had recent-
ly attended a clinic in the Midwest for a “check-
up.” During the process of examination, the phy-
sicians there had learned that he had been getting
up at night two times, and had noticed a little
slowing of his urinary stream. They therefore sent
him to have a residual urine check.

Having completed his check-up, he was dismissed
and sent home with the information that he had
an early prostate that someday might have to be
removed. By the time he got back to Des Moines,
he was in rather serious straits. His urine was
loaded with pus, and it was only with consider-
able difficulty that we were able to clean up his
urine with antibiotics. Fortunately, he was able to
get straightened out without further catheter
drainage, and an operation was not necessary.
These difficulties could all have been avoided if
he had not been checked for residual.

This has happened to my own patients, as it
has to many others, and I am sure that it will
happen again, since there are many times when
it is necessary to know the extent of a patient’s
residual urine, and catheterization becomes neces-
sary. Yet, this case points up the question of how
often is it really necessary to catheterize the early
prostate patient for residual urine.

In recent years, I believe, the average practic-
ing urologist has been catheterizing patients with
decreasing frequency, choosing rather to use other
means for determining whether or not his pa-
tients require further investigation of the prostate.
In nearly all instances there is a need for a survey
of the upper urinary tract by intravenous urog-
raphy, and if he simply has the patient void and
then obtains a post-voiding film, he gets a pretty
good idea of how much residual urine the patient
has. This is especially true if the patient’s urine
is negative to begin with. There is no use of run-
ning the risk of infecting him simply by placing
a catheter, which even under the most sterile
technic can still introduce bacteria into the blad-
der. If the patient has little, if any, residual, the
trauma of catheterization sets up the possibility
of recurrent cystitis. This condition can be ex-
tremely uncomfortable, and frequently the pa-
tient must have a catheter placed for further
drainage in order to get him over his dilemma.
Many times, the operation on the prostate is
hastened by this unfortunate occurrence.

The general surgeon is also at fault. It is very
easy to order an indwelling catheter for a patient
who is having any trouble at all in voiding after
an abdominal operation, and in some circumstances
it has become a routine procedure to order the
catheter without even giving the patient a trial
at voiding without one. I think this is a mistake.
Every patient should be given a chance to void,
and perhaps some of the “old fashioned” stimuli
such as sitting on the edge of the bed, hot water,
etc. should be used to help him. Catheterization
should be a last resort. Of course, a great deal of
extra work is involved for everyone concerned,
since it is so much easier to put in a Foley catheter.
Furthermore, catheterization provides assurance
that the patient’s bladder is not going to become
distended. But catheterization often introduces in-
fection, and we have seen innumerable patients
who have continued having bladder trouble fol-
lowing Foley catheter drainage, in spite of anti-
biotics.

Too often, the catheterization is cai-ried out by
someone whose sterile technic leaves considerable
to be desired. Not having any knowledge concern-
ing the anatomy of the urethra, some of these
people can do a great deal more harm than good
as they attempt to get a catheter into someone
whose urethra does not accept a catheter easily.

In spite of all the potent antibiotics that we have
today, we know that we are developing more and
more resistant strains of bacteria, and that we are
asking for trouble each time we introduce a new
strain of microorganism into anyone’s bladder by
means of a catheter.

The very act of catheterization can be a most
traumatic one. Should the patient have a large,
vascular prostate, a stricture or an irregularity in
the course of his urethra, the passage of a catheter
with too much force or from a poor angle can re-
sult in long-standing and almost irreparable dam-
age to the urethra itself. If and when the patient
has a prostatectomy, the resultant stricture forma-
tion or false passage can give the urologist no end
of trouble.

If it is absolutely necessary to introduce a
catheter, one should not put it in and take it out
more than once. It is preferable to leave it in place
until such a time as the patient is ambulatory or
until the physician feels that he can void under
his own power.

In diagnosing prostatism, catheterization for re-
sidual urine is a highly unnecessary procedure.
The same conclusions can be arrived at by other
means that are far less damaging to the patient’s
health. This is especially true in early prostate
cases, where there is considerable doubt in the
surgeon’s mind as to whether or not immediate
surgery is indicated. Certainly the surgeon
shouldn’t want to force the issue by producing
trauma or a serious infection that will require an
operation promptly.

230

Journal of Iowa Medical Society

April, 1962

Rare Diseases

Primary carcinoma of the Fallopian tube is a
rare disease. Only 14 cases were seen in the
Gynecological Clinic of the Johns Hopkins Hos-
pital during a 50-year period. Congenital absence
of the gallbladder, in association with normal
hepatic and common ducts, is a rare anomaly.
Gross states that approximately 38 cases have
been reported. Alveolar cell carcinoma of the lung
is an uncommon disease, if not rare. Pathologic
material at the Armed Forces Institute of Pathol-
ogy included only 39 cases at the time of a report
in 1953. Synovial sarcoma is a rare disease, only
60 cases having been seen by the Pack Medical
Group during a 20-year period. Encephalitis due
to cat-scratch fever is rare. Weber-Christian dis-
ease is comparatively rare. Retrograde intussuscep-
tion of sigmoid and descending colon without de-
monstrable cause, in an adult, is extremely rare.

Although the foregoing list of rare diseases is
not in itself overwhelming, it is of interest that
an example of each of those conditions has been
seen in recent years in the private practice of an
individual physician here in Iowa. Similar lists
could probably be compiled by all practicing phy-
sicians. The doctor who encountered the cases just
enumerated, like many other doctors with com-
parable lists, is not likely to report any of them in
the medical literature.

The point of all this is that most cases of rare
diseases are “lost” in obscure and forgotten rec-
ords, and the frequency of occurrence, let alone a
comprehensive study of each of them, is probably
inaccurately portrayed in published reports. Most
studies emanate from large medical institutions
and centers. Most cases, uncommon as well as
common, are seen by individual private practition-
ers. Perhaps some advances in medical knowledge
might result if a procedure were devised by which
cases of rare diseases could be readily reported and
catalogued. How could this be done, and by whom?

The American Medical Association is busy. Just
to protect its scalp along the New Frontier is al-
most a full-time job. Somehow it seems an im-
position to suggest that it undertake another duty.
However, because of its journal, it is probably
the only agency that can effectively and continu-
ously reach all of the doctors in the country. This
being true, it would be a logical organization to
collect reports of rare diseases.

There would still remain the problem of stimu-
lating reports from individual physicians. If each
issue of the journal of the American medical as-
sociation were to contain a tear-out, postage-col-
lect post card, addressed and providing a brief,
simple questionnaire for the doctor to fill out in
reporting his rare case, the response might be
imposing. The questionnaire could be limited to
the name of the rare disease, a means of identify-

ing the patient, the reporting doctor’s name and
address, and the whereabouts (hospital or doc-
tor’s records) of the information on the case. No
attempt need be made to define what constitutes
a rare disease, and no details or verification need
be asked for. Interested investigators could under-
take verification and detailed study at some later
time.

Surely if the reporting procedure were simple
and required but a few moments of time, most
doctors would be more than willing to play their
part in the accumulation of case material and
knowledge. The actual indexing and cataloguing
could doubtless be done by some type of electronic
machine, and the result would be an extensive
reference file of rare diseases, potentially a very
rich source of information.

Of course, this is just a wild idea, but some-
times wild ideas have merit. Sometimes not, too.

The Adjustment of Urinary pH Can
Be Important

According to Brumfitt and Percival,* of St.
Mary’s Hospital, London, autopsy studies includ-
ing microscopic examination of the kidneys have
revealed evidence of chronic pyelonephritis in
from 6 to 9 per cent of a large series of un-
selected patients, in many of whom the infection
had not been recognized clinically. The British
physicians suspect that the high incidence of
chronic pyelonephritis can be attributed to a failure
to treat urinary-tract infections adequately, with
the result that in some patients the infections have
persisted in sub-clinical forms and have ultimate-
ly progressed to chronic pyelonephritis. Numer-
ous articles in the American literature have ad-
vanced the same thesis.

In streptomycin therapy for urinary-tract infec-
tions at St. Mary’s Hospital, the failure to make
urine alkaline was an important shortcoming.
Brumfitt and Percival, indeed, regarded it as so
important that they conducted a laboratory inves-
tigation and a controlled clinical trial to demon-
strate the profound influence which the urinary
pH may have on the effectiveness of some of the
antibacterial agents.

In the laboratory study, numerous strains of
Escherichia coli, Streptococcus faecalis, Pseudo-
monas pyocyanea, Proteus bacillus, Paracolon ba-
cillus and Staphylococcus aureus were isolated
from patients with urinary-tract infections, and
sensitivity tests with various antibiotics were con-
ducted on nutrient agar plates with three levels
of pH: 5.5, 7.0 and 8.0. After the media had been

* Brumfitt, W., and Percival, A.: Adjustment of urine pH
in chemotherapy of urinary-tract infections: laboratory and
clinical assessment, lancet, 1:186-190, (Jan. 27), 1962.

Vol. LII, No. 4

Journal of Iowa Medical Society

231

inoculated, they were incubated at 37°C. for 18
hours, and the zone of inhibition about each anti-
biotic disc was measured. Identical studies were
made with liquid media. This laboratory investi-
gation revealed that proper adjustment of the pH
augmented the actions of a number of antibacte-
rial substances that are commonly used in the
treatment of urinary-tract infections. Streptomy-
cin was always more active under alkaline con-
ditions. The tetracyclines were more effective in
an acid medium. Chloramphenicol, it was found,
was least active at pH 7.0, and there was enhance-
ment when the pH was altered to either the acid
or the alkaline side, the result depending upon
the particular organism being studied. Nitrofuran-
toin was not significantly affected by a variation
in the pH. The sulfonamides resembled chlor-
amphenicol in that they showed variable responses
to the pH adjustment.

The clinical study assessed the value of com-
bined chemotherapy and urinary pH adjustment
in 102 patients. An equal number of patients re-
ceived chemotherapy alone. The presence of in-
fection was evaluated on the basis of a laboratory
examination of the urine, the criterion for infec-
tion being a bacterial count in excess of 100,000
organisms per milliliter of urine. If the leukocyte
count was less than 50,000/ml., the bacterial count
was repeated on another specimen before the pa-
tient was admitted to the study. Approximately
three-fourths of the patients had had symptoms
of primary urinary-tract infection for less than
one week. Patients with organic obstruction or
gross abnormality of the urinary tract were ex-
cluded, as were patients with neurologic disturb-
ance of the bladder.

The 102 controls were given the antibiotic of
choice in accordance with routine sensitivity test-
ing. The study group of 102 patients were given
the antibiotic of choice, and in addition an ad-
justment of the urinary pH in accordance with
whatever pH effect had been found in the labo-
ratory testing. The organisms isolated from pa-
tients in the two groups were very similar. There
was a wider variety of organisms in hospital pa-
tients than in outpatients, and some of the hos-
pital-acquired ones were resistant to a number of
commonly used antibiotics.

The results of chemotherapy in combination with
pH-adjustment were considerably better than
those achieved with chemotherapy alone. The cure
rate was 67 per cent in the control group, and 87
per cent in those who received the combined treat-
ment. The antibiotics that had been most in-
fluenced by pH-adjustment in vitro proved also to
be most influenced by it in vivo. Nitrofurantoin,
which had been very little affected by pH varia-
tions in the laboratory, gave identical clinical re-
sults in the control and in the combined therapy
groups. If the patients who were treated with
nitrofurantoin are excluded from both groups, the

success rate for the combined therapy group rises
to 91 per cent, as compared with only 64 per cent
of the patients who received the antimicrobial only.

An additional group of 136 patients with acute
urinary-tract infections who had relapsed after
four or five days of conventional chemotherapy
were given a five-day course of antibiotic therapy
after laboratory study and appropriate pH-adjust-
ment. In this group of 136 patients, there were 110
successes (81 per cent) and 26 failures (19 per
cent) .

The adjustment of pH was accomplished by the
administration of disodium hydrogen phosphate
when alkalinization was required, and of sodium
dihydrogen phosphate when acidification was
needed. These chemicals were given orally in
aqueous solution, in doses of 1 to 2 Gm. at six-
hour intervals. Patients were instructed in the use
of indicator paper, and adjusted their doses of
the pH-adjusting solution accordingly.

From this study, it would appear that rather
than depend upon chemotherapy alone in the treat-
ment of urinary-tract infections, one should give
careful attention to the influence of urine pH upon
the effectiveness of therapy. Whether an acid or an
alkaline urine will facilitate treatment should first
be determined in the laboratory through an in
vitro study of the influence of pH upon the anti-
biotic sensitivity of the infecting organism.

Annual University Issue

The editors of the journal wish to thank Dr.
David Culp and the members of his committee at
the S.U.I. College of Medicine for planning and
assembling the scientific articles for this issue.
Since, they secured considerably more material
for us than could be published this month, we
have found it necessary to postpone publication of
some of it until the May number.

Dean Norman B. Nelson, dean of the College,
Dr. John A. Gius, the director of postgraduate edu-
cation, and all of the other members of the faculty
are so consistently generous in sharing their sci-
entific findings with the readers of the journal
that there is rarely an issue that fails to contain at
least one presentation in addition to our highly
prized regular feature, the S.U.I. clinical pathologic
conference report. We are sure that the entire
membership of the Iowa Medical Society joins us
in this expression of our appreciation.

Help your central office to maintain an
accurate mailing list. Send your change of
address promptly to the Journal, 529-36th
Street, Des Moines 12, Iowa.

232

Journal of Iowa Medical Society

April, 1962

Presidents Page

I urge all physicians to circle May 13-16 on their
calendars, and to attend the 1962 Annual Meeting
of the Iowa Medical Society on those days.

The Program Committee has worked diligently to
develop a series of scientific presentations which will
be of interest and value to all physicians.

As a new feature this year, in addition to the var-
ious specialty meetings, a series of Fireside Confer-
ences on Cardiorespiratory Diseases will be held
Monday evening.

Tuesday will be “fun night” for those of you who
attend the Annual Banquet and Woman’s Auxiliary
Benefit Dance.

Details of the Annual Meeting appear on the fol-
lowing pages of this issue of the journal.

Plan now to attend!

President

IOWA MEDICAL SOCIETY

Organized in 1850

1962 ANNUAL MEETING

May 13-16

Veterans Memorial Auditorium
Des Moines

234

Journal of Iowa Medical Society

April, 1962

OTTO N. GLESNE, M.D.

President

Iowa Medical Society
1961-1962

General Sessions

General Sessions Room , Exhibit Hall

Monday Morning, May 14 11:45 a.m. Wendell G. Scott, M.D., St. Louis, Mis-

“Cerebral Vascular Malformations
and the Importance of Their De-

8:00 a.m. exhibits tection by Cerebral Angiography”

(The Arthur Erskine Memorial
Lecture)

8: 55 a.m. Invocation 12: 15 p.m. lunch

Rev. John M. Ness, pastor, St. Olaf
Lutheran Church, Fort Dodge

Monday Afternoon, May 14

9:00 a.m. President’s Address

Otto N. Glesne, M.D., Fort Dodge,
president of the Iowa Medical So-
ciety

9:30 a.m. Raymond G. Bunge, M.D., Iowa City
“Sex Determination”

2:00 p.m. Eugene S. Turrell, M.D., Milwaukee,
Wisconsin

“Does Your Patient ‘Need’ a Psychi-
atrist?”

2:30 p.m. Neal S. Bricker, M.D., St. Louis, Mis-
souri

“Fluid Balance in the Patient With
Chronic Progressive Renal Dis-
ease”

3:00 p.m. recess to visit exhibits

10:00 a.m. J. Nixon Briggs, M.D., Winnipeg, Mani-
toba

“Problems and Cooperation in Pre-
paid and Socialized Medicine”

10:30 a.m. recess to visit exhibits

3:45 p.m. Russell S. Fisher, M.D., Baltimore,
Maryland

“The Medical Examiner”

4: 15 p.m. Tague C. Chisholm, M.D., Minneapolis,
Minnesota

“Translation of Ivory-Tower Medi-
cine Into the Practice of Present-
Day Medicine”

11:15 a.m. Mr. James Brindle, Detroit, Michigan

“How Can Medicine and Labor Co-
operate to Assure the Best Pos-
sible Medical Care for the Ameri-
can People in the Present and
Future?”

The scientific program will he ac-
ceptable to the American Academy
of General Practice for 8^4 hours
of Category IT credit.

235

236

Journal of Iowa Medical Society

April, 1962

Edward R. Annis, M.D., of Miami, Florida (left), is chief of the Department of Surgery at Mercy Hos-
pital, Miami, a member of the Board of Directors of Family Service, and of the Senior Citizens’ Division
of the Welfare Planning Council, the chairman of the Legislative Committee of the Florida State Medi-
cal Association, and a recipient of the Brotherhood Medal of the National Conference of Christians and
Jews. Kenneth B. Babcock, M.D., of Chicago, Illinois (center), is director of the Joint Commission on
Accreditation of Hospitals, a trustee of the Blue Cross Commission, a guest lecturer in hospital admin-
istration at Columbia, Chicago, Northwestern and Minnesota Universities, and a fellow of the American
College of Surgeons. John C. Beck, M.D., of Montreal (right), is an associate professor of medicine at
McGill University, a research fellow at the McGill University Clinic of the Royal Victoria Hospital, the
chief of the Endocrine-Metabolic Unit at the same institution, a past-president of the Canadian Society
for Clinical Investigation, and a Markle Scholar in the medical sciences.

Neal S. Bricker, M.D., of St. Louis, Missouri (left), is director of the Renal Division in the Depart-
ment of Internal Medicine at Barnes and Wohl Hospitals, an assistant professor of medicine at the Wash-
ington University School of Medicine, an associate editor of the journal of laboratory & clinical med-
icine, an established investigator for the American Heart Association, and a visiting investigator at the In-
stitute of Biological Chemistry in Copenhagen, Denmark, 1961-1962. J. Nixon Briggs, M.D., of Winnipeg,
Manitoba (center), is an assistant professor of pediatrics at the University of Manitoba, the provincial
chairman of the Academy of Pediatrics, Manitoba Chapter, and president of Medical Executive Children’s
Hospital, Winnipeg. Mr. James Brindle, of Detroit, Michigan (right), is director of the Social Security
Department of the United Automobile, Aircraft and Agricultural Implement Workers of America
(UAW), a member of the Executive Committee of the Group Health Association of America, a member
of the Advisory Committee of the National Health Survey, U.S.P.H.S., and a member of the Research
and Development Advisory Committee of Michigan Hospital Service (Blue Cross).

General Sessions (Continued)

Tuesday Morning, May 15

8: 00 a.m. exhibits

9:00 a.m. Kenneth R. Cross, M.D., Iowa City

“Laboratory Personnel, Controls and
Procedures for the Practitioner”

9:30 a.m. Col. Joseph D. Goldstein, MC, USA,
Washington, D. C.

“Medical Aspects of Casualties in
Nuclear Warfare”

10:00 a.m. Edwin J. DeCosta, M.D., Chicago, Illi-
nois

“Office Gynecology, 1962”

10:30 a.m. recess to visit exhibits

11:15 a.m. Hon. Bourke B. Hickenlooper, U. S.
Senator, Cedar Rapids

“Report on Medical Legislation From
the Standpoint of a Legislator”

11:45 a.m. B. J. Kennedy, M.D., Minneapolis, Min-
nesota

“The Future of Cancer Chemother-
apy”

12:15 p.m. lunch

Tuesday Afternoon, May 15

2:00 p.m. Eugene Kaplan, M.D., Baltimore,
Maryland

“The Jaundice States in Children —
Causes and Treatments”

2: 30 p.m. Hubertus Strughold, M.D., San Antonio,
Texas

“Space Medicine”

3:00 p.m. recess to visit exhibits

3:45 p.m. John C. Beck, M.D., Montreal, Quebec

“Adrenal Cortical Physiology — Its
Clinical Implications”

4:15 p.m. Edward R. Annis, M.D., Miami, Flordia

“Current Legislative Proposals in
the Field of Medical Care”

Wednesday Morning, May 16

General Sessions Room, Exhibit Hall

Exhibits, on the main floor of the Auditorium,
will open at 8:00 a.m. The House of Delegates will
be recessed at 10:00 a.m. to enable the delegates to
visit the exhibits.

10: 20 a.m. special address

Kenneth B. Babcock, M.D., Chicago,
Illinois, director of the Joint Com-
mission on Accreditation of Hos-
pitals

11:30 a.m. report of the house of delegates

INSTALLATION OF THE PRESIDENT OF THE
SOCIETY

Meetings of the
HOUSE OF DELEGATES
will be held

Sunday, May 13 — 10:00 a.m.
Wednesday, May 16 — 8:00 a.m.
Veterans Memorial Auditorium

All members of the IMS are encour'
aged to attend these meetings.

237

238

Journal of Iowa Medical Society

April, 1962

R. G. Bunge, M.D., Iowa City (left), is a professor of urology at the SUI College of Medicine and a
diplomate of the American Board of Urology. Tague C. Chisholm, M.D., Minneapolis (center), is a clin-
ical professor of surgery at the University of Minnesota Medical School and chief of the Pediatric Surgi-
cal Service at Minneapolis General Hospital. Kenneth R. Cross, M.D., Iowa City (right), is acting chief
of the Laboratory Service, Veterans Administration Hospital, pathologist, Mercy Hospital, director of
the School of Medical Technology at the VA and SUI Hospitals, chairman of the IMS Subcommittee on
Exfoliative Cytology, a member of the Executive Committee of the Iowa Association of Pathologists, and
a councilor of the American Society of Clinical Pathologists.

Edwin J. DeCosta, M.D., Chicago (left), is an associate professor of obstetrics and gynecology at North-
western University, an attending gynecologist and obstetrician at Passavant Memorial Hospital, an attend-
ing gynecologist at Cook County Hospital, and a past-president of both the Central Association of Obste-
ti’icians and Gynecologists and the Chicago Gynecological Society. Russell S. Fisher, M.D, Baltimore
(center), is chief medical examiner of the State of Maryland, a professor of forensic pathology at the Uni-
versity of Maryland Medical School, a past-president of the American Academy of Forensic Sciences,
chairman of the Joint Committee of the Bar Association and Medical and Chirurgical Faculty of Mary-
land, and a member of the AMA-ABA Liaison Committee. Col. Joseph D. Goldstein, MC, USA, Wash-
ington (right), is chief of the Nuclear Energy Division of the U. S. Army Medical Research and Devel-
opment Command, and consultant in nuclear medicine to the Office of the Surgeon General of the Army.

Special Meetings and Dinners

Sunday, May 13

AMERICAN MEDICAL WOMEN’S
ASSOCIATION, IOWA BRANCH 19

The annual meeting of the American Medical
Women’s Association, Iowa Branch 19, will be held
at the home of Dr. Jean Glissman, 2031 70th
Street, Des Moines at 7:30 p.m. All Iowa medical
women are invited to attend.

GOLF TOURNAMENT

The Annual Golf Tournament will be held in
Des Moines at the Wakonda Club. Physicians may
begin play at any time during the day, but the
majority will start at 1 p.m. Dinner and awarding
of prizes will follow. Reservations should be made
with Dr. Harold J. McCoy, 212 Bankers Trust
Building, Des Moines 9.

IOWA SOCIETY OF INTERNAL MEDICINE

East Room — Savery Hotel

Business Meeting and Social Hour — 6:30 p.m.

Dinner — 7 : 30 p.m.

Reservations: D. A. Glomset, M.D.

2932 Ingersoll Avenue, Des Moines

Monday, May 14

AMERICAN COLLEGE OF CHEST
PHYSICIANS, IOWA MEDICAL SOCIETY

Veterans Memorial Auditorium

12: 00 noon Luncheon

12:30 p.m. Panel Discussion

“Management of the Cardiopulmo-
nary Cripple”

1:45 p.m. Business Meeting

Grand Ballroom — Hotel Savery

8:30 p.m. Fireside Conferences

(Reservation cards to be mailed to IMS members
in advance of meeting.)

IOWA ACADEMY OF GENERAL PRACTICE

Des Moines Room — Hotel Savery
Cocktails — 6 to 8 p.m.

All General Practitioners and their wives are
invited to attend. Tickets will be sold for $1.00
per person.

IOWA ACADEMY OF OPHTHALMOLOGY
AND OTOLARYNGOLOGY

Wakonda Club

Social Hour and Dinner — 6:30 p.m.

Reservations: C. C. Woodburn, Jr., M.D.

1421 Woodland Avenue, Des Moines

IOWA ACADEMY OF SURGERY

Wakonda Club

Business Meeting — 5 p.m.

Social Hour — 7 p.m.; Dinner — 8 p.m.

Reservations: A. N. Smith, M.D.

1407 Woodland Avenue, Des Moines

Attend the

FIRESIDE CONFERENCES

presented jointly
by the

AMERICAN COLLEGE OF CHEST
PHYSICIANS

and the

IOWA MEDICAL SOCIETY

Monday, May 14 — Grand Ballroom —
Hotel Savery — 8:30 pan.

A panel of physicians will be seated at each
of six tables to discuss and answer questions on
the following subjects:

Management of Emphysema

Treatment of Coronary Disease

Modern Treatment of Tuberculosis

Treatment of Hypertension

Congenital and Rheumatic Heart Disease

Bronchogenic Carcinoma

Refreshments ivill be served with the
compliments of the American
College of Chest Physicians

239

Journal of Iowa Medical Society

April, 1962

The Honorable Bourke B. Hickenlooper, Cedar Rapids (left), is senior U. S. Senator from Iowa. Eu-
gene Kaplan, M.D., Baltimore (center), is associate chief, Department of Pediatrics, Sinai Hospital of
Baltimore, Inc., and associate professor of pediatrics, Johns Hopkins University Medical School. B. J.
Kennedy, M.D., Minneapolis (right), is an associate professor of medicine at the University of Minne-
sota Medical Center.

Wendell G. Scott, M.D., St. Louis (left), is a professor of clinical radiology at the Washington Univer-
sity Medical School. Hubertus Strughold, M.D., San Antonio (center), is chief scientist, U.S.A.F. Aero-
space Medical Division (AFSC), Brooks Air Force Base. Eugene S. Turrell, M.D., Milwaukee (right),
is professor and chairman of psychiatry at Marquette University School of Medicine, director of psy-
chiatric services at Milwaukee Sanitarium Foundation, and consultant at the Hospital for Mental Dis-
eases of the Milwaukee County Institutions and Departments.

Special Meetings and Dinners (Continued)

IOWA ASSOCIATION OF PATHOLOGISTS
AND

IOWA SOCIETY OF MEDICAL
TECHNOLOGISTS

Des Moines Muncipal Airport
Social Hour — 6:30 p.m., Sky View Room
Dinner — 7:45 p.m., Green Room
Guest Speaker: Russell S. Fisher, M.D.,
Baltimore, Maryland

Chief Medical Examiner, State of Maryland
Reservations: F. C. Coleman, M.D.

Mercy Hospital, Des Moines

IOWA OBSTETRICAL AND
GYNECOLOGICAL SOCIETY

West Room — Des Moines Club

Social Hour — 6:30 p.m.; Dinner — 7:30 p.m.

Reservations: C. P. Goplerud, M.D.

University Hospitals, Iowa City

IOWA ORTHOPEDIC SOCIETY

South Room — Des Moines Club
Social Hour — 6 p.m.; Dinner — 7 p.m.

IOWA PSYCHIATRIC SOCIETY

Iowa Room — Savery Hotel
Business Meeting — 5:30 p.m.

Social Hour — 6:30 p.m.; Dinner — 7:30 p.m.
Reservations: H. C. Merillat, M.D.

2801 Woodland Avenue, Des Moines

IOWA RADIOLOGICAL SOCIETY

Business Meeting — 5 p.m., Room E, Auditorium

Colonial Room — -Des Moines Club

Social Hour — 6:30 p.m.; Dinner- — 7:30 p.m.

Guest Speaker: Wendell G. Scott, M.D.

St. Louis, Missouri

Reservations: Louis L. Maher, M.D.

1419 Woodland Avenue, Des Moines

IOWA SOCIETY OF ANESTHESIOLOGISTS

Parlors C-D, West Room — Hotel Savery

Social Hour — 6 p.m.; Dinner — 7 p.m.

Guest Speaker: William O. McQuiston, M.D.,
Peoria, Illinois

Reservations: T. A. Bond, M.D.

711 Equitable Building, Des Moines

PAST PRESIDENTS’ DINNER

Parlors A-B — Hotel Savery
Dinner — 7 p.m.

Tuesday, May 15

LEGISLATIVE CONTACT MEN

Des Moines Room — Hotel Savery
Breakfast — 7:30 a.m.

PRESIDENT’S RECEPTION AND
ANNUAL BANQUET

Hotel Savery

Reception, 6 p.m. — Grand Ballroom
Banquet, 7 p.m. — Des Moines and Terrace Rooms

BENEFIT DANCE

“Caduceus Capers”

Des Moines and Terrace Rooms — Hotel Savery
8: 30 p.m.

Evan Morgan’s Orchestra

Sponsored by the Woman’s Auxiliary for the
Benefit of Its Health Educational Loan Fund

241

The House of Delegates

Open to all members

SPEAKER

First Meeting — Sunday
May 13, 10:00 a. m.

South Room , Veterans Memorial
Auditorium

Roll Call

Approval of the Minutes of the
Meeting held on April 26, 1961

Reports of Officers

Nominations

Reports of Committee Chairmen
Memorials and Communications
New Business

C. V. Edwards, Sr., M.D.

Second Meeting — Wednesday
May 16, 8:00 a.m.

General Sessions Room , Veterans
Memorial Auditorium

Roll Call

Reading of Minutes
Election of Officers
Reports of Committees
Unfinished Business
New Business
Adjournment

Program Committee

C. J Baker, M.D.
Chairman

C. N. Hyatt, M.D.

R. C. Larimer, M.D.

V. W. Peterson, M.D.

V. L. Schlaser, M.D.

242

SCIENTIFIC EXHIBITS

State University of Iowa College of Medicine

Mental Retardation in Young Children — Robert
B. Kugel, M.D., Child Development Clinic, De-
partment of Pediatrics

Pathology of Child-Parent Relations— Richard

L. Jenkins, M.D., Child Psychiatry Service, State
Psychopathic Hospital

Agricultural Medicine — Institute of Agricultural
Medicine

College of Medicine Administration — Miss Alice
White, Dean’s Office

Phrenico-Facial Anastomosis for Facial Paraly-
sis— George Perret, M.D., Robert Hardy, M.D.,
Russell Meyers, M.D., F. Miles Skultety, M.D.,
Division of Neurosurgery, Department of Sur-
gery

Techniques for Studying Speech Physiology —
James C. Hardy, Ph.D., Kenneth L. Moll, Ph.D.,
Hughlett L. Morris, Ph.D., and Duane C. Spries-
tersbach, Ph.D., Department of Otolaryngology
and Maxillofacial Surgery

Arthritis Avenue — Rheumatism Street — Physical
Therapy Department, Department of Physcial
Medicine and Rehabilitation, University Hos-
pitals; and Iowa Chapter Arthritis and Rheuma-
tism Foundation, State Headquarters, Des
Moines.

Veterans Administration Center, Des Moines

Hemorrhaging Chronic Duodenal Ulcer: A New
Look at an Old Problem — Louis T. Palumbo,

M. D., and Wendell S. Sharpe, M.D., Surgical
Service

General

Fresh Cervical Cytology by Interference Mi-
croscopy— Donald V. Hirst, M.D., Council Bluffs

A Demonstration of Digital Computer Interpre-
tation of Electrocardiograms — John E. Gustaf-
son, M.D., Des Moines

Comprehensive Rehabilitation — Younker Memo-
rial Rehabilitation Center, Iowa Methodist Hos-
pital

Emergency Medical Care — Committee on Emer-
gency Medical Service, Iowa Medical Society

The American Cancer Society’s Attack on Can-
cer of the Colon and Rectum — American Can-
cer Society, Iowa Division, Inc.

Epidemiology of Infectious Hepatitis — Polk
County 1961 — Des Moines-Polk County Health
Department

Serving the Doctor and the Public— Polk County
Medical Society

Iowa Chapter of the American Academy of Gen-
eral Practice

Iowa Association of Pathologists
Iowa Pharmaceutical Association
Laboratory Animals in Research — Brucellosis —
Iowa Veterinary Medical Association
Iowa Association of Medical Assistants
Automation in the Laboratory — Iowa Society of
Medical Technologists

American Society of X-Ray Technicians — Iowa
Society of X-Ray Technicians
Dental Health Education — Iowa Dental Hygien-
ists Association

Chemistry, Chromosomes and Congenital Anom-
alies— The National Foundation
Your Heart Association Serves the Physician —
Iowa Heart Association

Tuberculin Skin Test Every Patient; Chest X-
Ray Every Reactor— Iowa Thoracic Society
Aid to the Partially Seeing — Iowa Society for
the Prevention of Blindness
Easter Seal Treatment Center — Polk County
Society for Crippled Children and Adults
Parameters of Normal Speech Development — Des
Moines Hearing and Speech Center
Multiple Sclerosis — “What Is It?”— Central Iowa
Chapter, National Multiple Sclerosis Society
Myasthenia Gravis — Iowa Chapter, Myasthenia
Gravis Foundation, Inc.

Human Betterment League of Iowa
Adoption and Related Services — Iowa Children’s
Home Society

Know Your Iowa Gems and Minerals — Des
Moines Lapidary Society

Pinpointing Vocational Rehabilitation — Iowa
State Department of Public Instruction, Division
of Vocational Rehabilitation
Syphilis Is Where You Find It — Iowa State De-
partment of Health, Division of Venereal Dis-
ease Control

Prevent Infectious Hepatitis — Iowa State Depart-
ment of Health, Division of Health Education
Screening Children for Heart Disease With the
Use of Recorded Heart Sounds — Iowa State De-
partment of Health, Division of Gerontology,
Heart and Chronic Diseases
Some Methods for Evaluating Hearing Acuity —
Iowa State Department of Health, Committee on
the Conservation of Hearing for the State of
Iowa

Vital Statistics System of the United States —
Iowa State Department of Health, Division of
Vital Statistics

Nutrition Service Offers an Education Program
— Iowa State Department of Health, Nutrition
Service

243

TECHNICAL EXHIBITORS

Abbott Laboratories, North Chicago, Illinois
Ames Company, Inc., Elkhart, Indiana
Anderson Pharmaceuticals, Columbus, Ohio
Baker Laboratories, Inc., Cleveland, Ohio
Blue Cross-Blue Shield Plans, Des Moines-Sioux
City

Breon Laboratories, Inc., New York, New York
Carnation Company, Los Angeles, California
CIBA Pharmaceutical Products, Inc., Summit, New
Jersey

Cusack-Harmon Company, Sioux City, Iowa
DePuy Manufacturing Co., Inc., Warsaw, Indiana
Desitin Chemical Co., Inc., Providence, Rhode
Island

Dictaphone Corporation, Des Moines, Iowa
Endo Laboratories, Inc., Richmond Hill, New York
Marshall Erdman and Associates, Inc., Madison,
Wisconsin

Foot-so-Port Shoe Company, Waterloo, Iowa
Geigy Pharmaceuticals, Ardsley, New York
H. & J. Supply Company, Des Moines, Iowa
Holland-Rantos Company, Inc., New Yoi’k, New
York

Holmes, Prouty, Murphy & May, Des Moines, Iowa
King Merritt & Company, Inc., Des Moines, Iowa
Lazy M Shoe Stores, Des Moines, Iowa
Lederle Laboratories, Pearl River, New York
Eli Lilly and Company, Indianapolis, Indiana
J. B. Lippincott Company, Philadelphia, Pennsyl-
vania

Loma Linda Food Company, Arlington, California
Marion Laboratories, Inc., Kansas City, Missouri
S. E. Massengill Company, Kansas City, Missouri
Mead Johnson Laboratories, Evansville, Indiana
Medco Products Company, Inc., Tulsa, Oklahoma
Medical Protective Company, Fort Wayne, Indiana
Merck, Sharp & Dohme, West Point, Pennsylvania
Merrill Lynch, Pierce, Fenner & Smith, Inc., Des
Moines, Iowa

Milex Professional Specialties, Peoria, Illinois
Mutual Benefit Life Insurance Company, Des
Moines, Iowa

National Drug Company, Philadelphia, Pennsyl-
vania

Ortho Pharmaceutical Corporation, Raritan, New
Jersey

Parke, Davis & Company, Detroit, Michigan
Pepsi-Cola General Bottlers, Inc., Des Moines,
Iowa

Pfizer Laboratories, New York, New York
Pharmich Laboratories, Cedar Rapids, Iowa
Physicians and Hospitals Supply Company, Minne-
apolis, Minnesota

Physicians & Surgeons Underwriters Corporation,
Minneapolis, Minnesota
Picker X-Ray, Midwest, Inc., Omaha, Nebraska
Plough Laboratories, Inc., Memphis, Tennessee
Riker Laboratories, Inc., Northridge, California
A. H. Robins Company, Inc., Richmond, Virginia
Robinson Wholesale Company, Des Moines, Iowa
Roche Laboratories, Nutley, New Jersey
J. B. Roerig and Company, New York, New York
William H. Rorer, Inc., Philadelphia, Pennsylvania
Ross Laboratories, Columbus, Ohio
Ryter Corporation, Milwaukee, Wisconsin
Sandoz Pharmaceuticals, Hanover, New Jersey
W. B. Saunders Company, Philadelphia, Pennsyl-
vania

Schering Corporation, Union, New Jersey
G. D. Searle & Company, Chicago, Illinois
Smith, Kline & French Laboratories, Philadelphia,
Pennsylvania

E. R. Squibb & Sons, New York, New York
Standard Medical & Surgical Company, Des
Moines, Iowa

Thermo-Fax Dealers of Iowa, Des Moines, Iowa
Ulmer Pharmacal Company, Minneapolis, Minne-
sota

Upjohn Company, Kalamazoo, Michigan
U. S. Vitamin & Pharmaceutical Corporation, New
York, New York

Warner-Chilcott Laboratories, Morris Plains, New
Jersey

Warren-Teed Products Company, Columbus, Ohio
Westwood Pharmaceuticals, Buffalo, New York
Winthrop Laboratories, New York, New York

ATTENTION ALL AKTISTS!

You are invited to display your original art and sculpture work at an

ART EXHIBIT

sponsored by tSie Woman’s Auxiliary. All IMS members and tlieir wives
are encouraged to participate.

Entries will be received at Veterans Memorial Auditorium on

Sunday, May 13 — 1 :30 to -1 :30 p.m.

Awards will be made in four general categories: oils and wratereolors ; sculp-
ture; drawing; and graphic art.

For entry blanks and specific information, write to:

Mrs. F. M. Burgeson, Exhibit Chairman
1166 Chatauqua Parkway, Des Moines, Iowa

244

THE JOURNAL FcokSkdf_

BOOKS RECEIVED

CURRENT THERAPY— 1962, ed. by Howard F. Conn, M.D.
(Philadelphia, W. B. Saunders Company, 1962. $12.50).

THE MONTEGGIA LESION, hy Jose Luis Bado, M.D., tr. by
Ignacio V. Ponseti, M.D. (Springfield, Illinois, Charles C
Thomas, 1962. $6.75).

THE DOCTORS’ DILEMMAS, by Louis Lasagna, M.D. (New
York, Harper & Brothers, 1962. $4.95).

MODERN CONCEPTS OF HOSPITAL ADMINISTRATION,
ed. by Joseph Karlton Owen, Ph.D. (Philadelphia, W. B.
Saunders Company, 1962. $16.00).

GENERAL PATHOLOGY, THIRD EDITION, ed. by Sir How-
ard Florey. (Philadelphia, W. B. Saunders Company, 1962.
$22.00).

ERRANT WAYS OF HUMAN SOCIETY, by Julius Bauer,
M.D. (New York, Vantage Press, Inc., 1962. $3.00).

NEW AND NONOFFICIAL DRUGS, 1962, evaluated by the
AMA Council on Drugs. (Philadelphia, J. B. Lippincott
Company, 1962. $4.00).

SURGERY OF THE AMBULATORY CHILD, by S. Frank
Redo, M.D. (New York, Appleton-Century-Crofts, Inc.,
1961. $8.50).

PRACTICAL MANAGEMENT OF THE OBESE PATIENT, by
Frank L. Bigsby, M.D., and Cayetano Muniz, M.D. (New
York, Intercontinental Medical Book Corporation, 1962.
$4.00).

BOOK REVIEWS

Textbook of Endocrinology, Third Edition, by Robert
H. Williams, M.D. (Philadelphia, W. B. Saunders
Company, 1962. $21.00).

Periodically, in the busy medical-political-commu-
nity-family life that the physician leads, he realizes
that the pioneers in one or another of the fields of
medical knowledge have far outdistanced him — have
indeed disappeared over the horizon. Then, if he is
conscientious, he seeks out a recent monograph on the
particular subject in an effort to catch up. This book
is really an edited collection of such monographs, but
it provides an added service. It simultaneously sum-
marizes the established facts and also reviews the
currently accepted theories concerning those of our
internal organs known collectively as the endocrine
glands. It is an exceptionally well done piece of work.

Knowledge concerning the pathologic physiology of
the various endocrine glands has been enormously ex-
panded within the past six or seven years. Indeed, this
book makes it clear that the time is rapidly ap-
proaching when we shall talk, not of the relatively
gross pathologic physiology, but rather of the patho-
logic molecular chemistry of a particular abnormality.
A decided tendency is also developing to refer etio-
logic concepts back to original specific genetic de-
fects. The greatest strides, in the recent past, have
been taken in clarifying the etiologic and develop-

mental aspects of endocrine disturbances, but one has
the feeling that similarly rapid advances will soon
occur in the therapeutic area.

The only annoying thing about this book is the
all too frequent use of capital-letter abbreviations.
The authors seem to forget that they are not writing
for the benefit of their fellow academicians, but are
attempting to produce a reference book that the prac-
titioner will find readily readable. Furthermore, the
code does not follow a consistent pattern. Sometimes
the successive capital letters stand for separate words,
and at other times they refer to successive syllables
within a single word. I wonder how many internists
can translate the statement that TRC is useful in
evaluating the EHF, EPS and TTH blood levels. It is
true that each term is written out in full when it is
first mentioned, but that doesn’t help one much when
he has been referred, by the Index, to the middle of
a chapter and is confronted with an unintelligible
alphabet soup.

This is not to say that this book fails to provide
very practical diagnostic and therapeutic help, for it
does. Therefore, I believe it deserves a place on the
ready reference book shelf of every practicing phy-
sician.— L. J. Kirkham, M.D.

Trial of Medical Malpractice Cases, by David W.

Louisell and Harold Williams, M.D. (Albany, Mat-
thew Bender & Company, 1960. $25.00).

It is a peculiar characteristic of human affairs that
great prestige, success or power are very often ac-
companied by pain, uncertainty or loss, in an amount
almost equal, if such things could be measured, to
the pinnacles achieved. Emerson’s law of compensa-
tion is no respecter of persons or institutions.

So it is not surprising that the profession of medi-
cine, at the time of its greatest accomplishment, with
promise of much more to come, should be profoundly
troubled and sorely beset on several fronts. Doctors
are worried about “socialized medicine,” about medi-
cal education, about rising costs, about taxes. And if
these were not enough, there looms always the spectre
of a suit for medical malpractice.

Now it has been the common experience of both
medicine and the law to be ridiculed and belittled;
perhaps this is because members of the two profes-
sions deal with such vital human problems as to pre-
sume to play the part of demigods — and for pay. In
any event, if the lawyer winces at Daumier’s car-
toons, the doctor has his copy of mad magazine with
its cartoon “Great Moments in Medicine — Presenting
the Bill.” Such caricatures are the price we pay for
the function we are bold enough to perform.

The threat of an action for medical malpractice is
more immediate and pressing. It says to the doctor:

245

246

Journal of Iowa Medical Society

April, 1962

“You have fallen below the standards of your profes-
sion; you have injured another; you must pay.” In a
way it puts him, in his own eyes, in the position of
the careless driver or the negligent bottler of mice in
pop bottles.

Whatever the case, the reaction to the growing
number of malpractice cases (and the sizes of awards)
has been to produce what is almost hysteria among
many of those who speak for medicine. The lawyer
comes to be looked on as a greedy shyster represent-
ing a shamming patient, regardless of social conse-
quences; solemn statements are made to the effect
that if this sorry state of affairs persists no one will
dare to practice the healing arts. To make matters
worse, the journalists have taken up the hue and
cry. In consequence, many unwise things have been
said by or on behalf of physicians.

For their part, many lawyers have overstated their
side of things. Statements as emotionally charged as
anything the doctors have said have been made both
privately and for mass consumption. Some of our
legal brethren, fearless of personal publicity, have gal-
loped forth on white chargers hurling arrows labelled
“conspiracy of silence” and “legalized butchery.” Too
little legal writing has come from the head; much too
much has been heard from the belly.

The result has been to obscure a problem of the
gravest concern to every one of us. The area of medi-
cal malpractice is an exceedingly difficult one for
anyone to understand. Few of us lawyers can imagine
the lonely burden of decision laid upon the phy-
sician in diagnosis and in treatment. We have, perhaps,
been oversold on what modern medicine really knows,
or what it can do; this deification of the man in the
white coat carries within itself the seeds of its own
destruction: Lucifer has farther to fall than Adam.
On the other hand, the medical profession has not
been taught the nature of its responsibility in law, nor
yet what the law seeks to do, and how it goes about
it. What is a most difficult and complex dilemma too
often has been emotionally, not rationally, handled.

This is not to say that we have not had some ex-
cellent research and writing on the subject, nor that
sensible members of both professions have not tried
various means toward eliminating tensions and chi-
canery. One thinks of impartial panels and “screen-
ing” technics. But up to now, there has been no one
work to which a lawyer could turn with confidence
that both the legal and the medical aspects of malprac-
tice litigation would be intelligently, informedly and
impartially set forth.

I say “up to now,” because I think Mr. Louisell and
Dr. Williams have given us the book we have needed.
You will notice at the outset that this book is the re-
sult of the collaboration of an eminent legal scholar
and a physician. Too often, past literature has been
special pleading or the work of a physician-lawyer;
even in the latter case it is hard to avoid the appear-
ance of bias. And it is likely to be poor stuff when
lawyers write about medicine, or doctors write about
the law.

Thus, I do not doubt that Chapter II, “Insight for
the Lawyer into the Practice of Medicine,” was pri-
marily the work of Dr. Williams. What lawyer could
have written it? If this chapter, and it alone, had
been all that I, as a lawyer, had studied in the book,
it would have been worth it. True, we pick up bits
and pieces of insight into the doctor’s dilemma, but

never the whole. Here it is expressed simply, force-
fully, candidly. Lawyers, for example, sense the in-
fluence of their colleagues upon their own attitudes
and actions as lawyers. How many have given
thought, when faced with a medical-legal problem, to
the similar situation in medicine? How many of us
have recognized the influence of hospital staffs upon
individual physicians?

Or, to look at it from the other side, how many
physicians truly grasp the nature of our adversary
system — unscientific, seemingly disorganized, some-
times apparently designed to embarrass or obfuscate?

But this book contains a great deal more — more
than can be discussed in a book review. I should like
to single out a few areas especially well handled.

One of these is that thorny “menagerie case,” res
ipsa loquitur. I do not recall a more accurate or con-
cise statement of the reason for the rule and the
causes of its rapid push into medical malpractice
cases. To be sure, our authors may seem to over-
simplify what some have made most intricate, but one
should not automatically equate complexity with
scholarship. Whitehead once said of Lord Russell’s
discussion of a certain aspect of Christian theology,
“He left the darkness completely unobscured.” It is
also worth noticing that the authors, drawing upon
personal observations (in California, of all places!),
call attention to the fact that defendants are beginning
to demand trial by jury. Res ipsa may not be the ir-
resistible force that many have supposed it to be. And
I quite agree that a major weakness in the applica-
tion of res ipsa loquitur in medical malpractice cases,
as complicated as they are likely to be, has not come
from the doctrine itself but from the manner in
which trial courts have instructed juries thereon.
Textbook explanations of the “rule” have to be care-
fully and specifically related to the evidence pre-
sented in the case if res ipsa is to mean anything
even to the most intelligent of jurors

This reviewer also liked Chapter III, “The Fields
of Medicine — Clues to Perspective.” A lawyer sea-
soned in personal injury litigation will have gotten
some idea of the function of the urologist or the
dermatologist, but he may be unaware of the functions
of other specialties. A lawyer less experienced is un-
likely to understand any of the boundary lines or the
medical justification for them.

The impartiality of coverage which stamps this book
is shown by Chapter VI, “The Lawyers’ Insight Into
Physicians’ Notions of Malpractice,” as well as by
Chapters XI and XII, dealing respectively with
handling a case for plaintiff and one for defendant.

I also found Chapter XIX, “Future Sources of Ac-
tions— Exploitation and Prevention” most stimulating.
This is not so much a come-on for the NACCA [Na-
tional Association of Claimants’ Compensation Attor-
neys] enthusiast as he might expect, it is no collection
of hot tips or novel sources of liability to be had for
the price of the book. Rather, it should be taken as
a serious warning to all concerned of possibilities un-
plumbed. In this category, for example, are blood
transfusions, psychiatric complications and excessive
use of antibiotics (perfect examples that increased
knowledge increases responsibilities.) As a matter of
fact, doctors of any competence whatever know per-
fectly well the risks involved in such things as the
wholesale use of antibiotics, and should not be unduly
taken aback on the day when suit is brought upon

Vol. LII, No. 4

Journal of Iowa Medical Society

247

such a cause of action. The authors’ attitude is not
one of “Eureka!” but one of sober assessment and
prevention.

Chapter XX on malpractice insurance is very use-
ful and informative. It contains a good discussion of
insurance company practice, which is frequently as
important as policy terms, but may not be within the
experience of many lawyers.

Finally, I commend the malpractice case reference
list in Appendix A. Under headings beginning with
“Abortion” and ending with “X-ray Injuries Associ-
ated With Therapy,” leading cases are cited with a
shorthand description of the meat of each. Since this
book is in loose-leaf form, it will be easy to keep the
list up-to-date, and that is particularly useful in an
expanding field.

Throughout the book, the advantage of collabora-
tion of doctor and lawyer in two separate persons
shines forth. When medical matters are dealt with,
you can be sure it is a doctor speaking as a doctor
whom you hear, not a lawyer who has had a medical
education on the side. This makes for greater con-
fidence on the reader’s part in statements made and
opinions rendered.

If I have a criticism of the general nature of the
book, it is that it is aimed at the lawyer primarily.
This is necessarily so if a book is to be thorough,
scholarly and professional. Yet it is a pity more doc-
tors will not read it. Bombarded as physicians are by
propaganda hostile to the very idea of malpractice
liability, they should see the balanced side of the
argument so competently furnished by this book. This
would be therapy indeed, and it is long overdue.

In sum, every lawyer who is in any way concerned
with medical malpractice litigation should have this
book. Every so often some gap in our legal literature,
crying for action, is at last plugged by a piece of
scholarly work equal to the task. . . . That has at last
happened for medical malpractice litigation, and I
congratulate the authors on a pioneering work which
has overcome a climate of hot emotionalism and a
terrain of many perplexing and ill-considered cases
to reach the Promised Land — a book on medical mal-
practice which cannot help but become the measure
of all else that follow. — Samuel M. Fahr, professor of
law at S.U.I.*

* Reprinted from iowa law review, 47:543-546, (Winter)

W. B. SAUNDERS COMPANY features the fol-
lowing recent books in their full page advertise-
ment appearing on page vii in this issue:

ADLER— TEXTBOOK OF OPHTHALMOLOGY
Concentrates on the ophthalmic problems of
the non-specialist — stressing diagnosis, treat-
ment and indications that call for a specialist.
MAJOR AND DELP— PHYSICAL DIAGNOSIS
Offers step-by-step procedures for examining
every area of the body by inspection, palpa-
tion, percussion and auscultation.

REID— TEXTBOOK OF OBSTETRICS
Gives you not only a clear picture of normal
pregnancy and labor, but sound insight as well
into the medical complications that may arise.

The Mold of Murder, by Walter Bromberg, M.D. (New

York, Grune & Stratton, Inc., 1961. $4.75) .

The author works toward finding solutions for the
expensive and fruitless way in which our society
deals with its criminals. His wealth of information,
accompanied by sometimes brilliant thought, about
the psychodynamics of criminals in general and of
murderers specifically, has been collected during his
years of experience with prisoners in civilian as well
as military (naval) penal institutions.

In a systematic study, with illustrations from case
histories and court records, Dr. Bromberg attempts
to assess the close similarities and the apparently
minor differences between the dynamics of the non-
criminal and those of the criminal. It is this review-
er’s opinion that the book does not explain clearly
what factors enable the majority of individuals (who
as Dr. Bromberg points out, “love their murders but
hate their criminals”) either to keep their own mur-
derous wishes altogether out of their conscious aware-
ness, or to control and integrate them, whereas the
criminal acts upon his destructive impulses.

I wish to take exception to three points in the
book. Psychodynamically experienced and sophisti-
cated professional psychotherapists — i.e., social work-
ers, psychodynamically oriented psychologists or psy-
chiatrists who, through their own experience, are in
position to evaluate Dr. Bromberg’s findings and de-
ductions— may profit greatly from reading this study.
However, for interested laymen and lay workers who
have had no clinical experience upon which to evalu-
ate what he says, the book is far too complicated.
Therefore, although it may be thought-provoking, it
is not only useless but dangerous as a guide for pro-
bation officers and other lay workers.

My second point concerns what he calls his “analytic
procedure,” which he required of a 19-year-old delin-
quent prisoner during daily interviews. His “analytic
method” consists of requiring the subject to lie down
on a couch and to use “free association.” I consider
the classical psychoanalytic approach wiser, less au-
thoritative and thus less destructive to the subject
than Dr. Bromberg’s “analytic method.” In the psycho-
analytic method the therapist would explain to the
subject the purpose of the proposed sessions and
their possible value to him. The prisoner would then
be left to decide whether he wished to enter treatment.
This experience in itself would accord the subject the
dignity due to any individual, whether a criminal or
not, and particularly one whose latent ability to love
one wishes to awaken, and would not incite him un-
necessarily, as an authoritative demand for a particu-
lar procedure would do.

Furthermore, a 19-year-old delinquent lacks enough
strength of the ego (integrative function of the per-
sonality) to use a couch. From a psychoanalytic point
of view, he should sit up, for on the couch he would
almost at once regress to a negative transference (i.e.,
begin to transfer negative childhood attitudes on to
the doctor) and in addition, with a man therapist,
the reclining position is contraindicated since it im-
mediately and unnecessarily overloads the patient’s
feelings with homosexuality— all of which Dr. Brom-
berg’s subject manifested. The technic may have been
helpful in eliciting “interesting” psychological informa-
tion, but this reviewer considers investigative pro-
cedures justified only if they are also therapeutic and

248

Journal of Iowa Medical Society

April, 1962

if the therapist can expect to carry the patient until
the patient can deal with his problem.

My third point concerns Dr. Bromberg’s final sug-
gestion, for the future, that delinquency may be dealt
with by familiarizing society at large (a psychiatrically
unscreened audience) with its own psychodynamics
through the use of television as a medium for gen-
eral psychodrama — a form of group psychotherapy
designed to enable all interested individuals to deal
more directly with, and thus learn to master, their
own unacceptable impulses. I think such a proposal
is utopian and a result of the author’s over-simpli-
fying, mechanistic-materialistic approach.

He overlooks the therapeutic agents necessary for
a constructive outcome of psychotherapy. The indi-
vidual can make constructive use of a growing aware-
ness of his own destructive impulses only if, at the
same time, his latent ability to love — to identify with
the members of the group in group therapy, or with
the therapist in individual therapy — is given a chance
to develop. Over television, when the audience con-
sists principally of observers rather than of true mem-
bers of the group, the viewer would find it difficult to
identify sufficiently, and thus therapeutically, with
the performances. Without such identification and
without the constant supervision of the therapist,
viewers who possess only marginal ego strength might
become psychotic or delinquent in the process of be-
coming aware of their own destructive impulses.—
Ada Dunner, M.D.

The Abortionist, by Dr. X as told to Lucy Freeman.
(New York, Doubleday & Co., Inc., 1961. $3.95).

“Take a city, any big city in America, and that is
where I live, two of me, ten of me, twenty of me. No

city can do without me. I am considered the out-
rageous attendant of outrageous love — an abortionist.”

These words open the story of a very successful
abortionist — very successful, that is, until he got
caught! His statistics must be right, for it is estimated
that over a million criminal abortions are performed
yearly in the United States. The anonymous co-author
of this book says he relieved over 25,000 women of
their unwanted pregnancies — married and unmarried
women of all races and of all religions. Apparently he
was one of the “good” ones, employing meticulously
sterile technic, utilizing the services of a doctor-anes-
thetist and well trained nurses. He had an operating
room, a recovery room — -in fact, a complete abortion-
arium. His patients came to him, or were referred to
him, from all walks of life and all social strata, from
remote parts of the United States and from other
countries.

He feels that it is criminal that unqualified — indeed
often nonmedical — people are killing or maiming our
women by botching the job.

His fees ranged from “nothing” (because he was
compassionate) to $10,000, and on his busiest day he
handled 27 patients. A friend of his handles 10,000 pa-
tients per year in his “well run abortionarium.” Dr.
X does not feel, however, that money was the most
important reason for his choice of specialty; he had
a genuine desire to relieve the suffering caused by
the continuance of an unwanted pregnancy. After all,
he insists, an abortion is not, in itself, an illegal pro-
cedure. Only when it is done for reasons not recog-
nized by the courts does it become a criminal act, and
those reasons may vary from state to state. He feels
that our present abortion laws are too strict and con-
fining, and that a liberalization of them should be
considered. — H. Kirby Shiffler, M.D.

Sixth Annual Blank Hospital
Pediatric Conference

Younker Memorial Rehabilitation Center, Des Moines

Friday, April 13

8: 30 a.m.
9: 00 a.m.

1:00 p.m.
2: 00 p.m.

REGISTRATION
MORNING SESSION

“Biological Effects of Bilirubin”— Robert A.
Aldrich, M.D., head of pediatrics, Univer-
sity of Washington, Seattle
“Disturbances of Growth in Children” — John
D. Crawford, M.D., assistant professor of
pediatrics, Harvard University
“Problems of Unexplained Fever” — Robert
B. Lawson, M.D., head of pediatrics,
Northwestern University
business meeting — Iowa Chapter, American
Academy of Pediatrics
afternoon session

Clinical Presentation — Resident pediatric

staff

“Detection and Significance of Hemorrhagic
Disease in Children” — Irving Schulman,

M.D., head of pediatrics, University of
Illinois

5: 00 p.m. business meeting — Iowa Pediatric Society

7:00 p.m. social hour and dinner — for physicians and
their wives and guests, at the Des Moines
Club

Saturday, April 14

9:00 a.m. morning session

Clinical Presentation — Resident pediatric
staff

“Why We Succeed: Homeostatic Mecha-

nisms”— Dr. Crawford

“Drug-Induced Aplastic Anemia” — Dr. Schul-
man

2: 00 p.m. afternoon session

“Differential Diagnosis of Collagen Diseases
in Children” — Dr. Aldrich
“Problems of Overtreatment in Pediatrics” —
Dr. Lawson

The Seventh Annual Refresher Course
at S.U.I.

Members of the Iowa Chapter of the American
Academy of General Practice enjoyed an interest-
ing refresher course put on by the faculty of the
College of Medicine at the University in Iowa City,
February 13-16. Attesting to the quality of the pro-
gram was the fact that the lecture hall at Univer-
sity Hospitals was filled from the first to the last
hour on each of the four days.

This is the seventh year in which such a course
has been presented by the College of Medicine for
the benefit of the family doctor, and the program
has grown in popularity each year. Two hundred
thirty-five physicians registered this year, includ-
ing 31 from outside Iowa, some having come from
as far away as Texas and Wyoming. Seven of the
out-of-state general practitioners were “repeaters,”
having enjoyed one or more similar courses pre-
viously.

Between lectures, many of the physicians said
that for a person accustomed to the activity of a
busy office, the hardest part of the course was sit-
ting all day taking notes. It was interesting to note
how different were the kernels of information that
seemed important to various ones of the listeners,
depending no doubt upon the particular symptoms
displayed by their most perplexing patients back
home. This is probably the secret of the popularity
of the refresher course put on by our College of
Medicine. The specialists from the halls of learning
don’t merely give us an outline of what to do until
the surgeon arrives, or the internist or the gyne-
cologist. They show us the new and better methods
of diagnosis and treatment so that we can use them
on the patients we all see in our offices.

The first day, Tuesday, we were in surgery —
almost literally so — for we were given five presen-
tations on practical technics over closed-circuit
television. The view we received over six TV
sets, carefully placed in the lecture hall, let us see
almost as clearly as if we had been doing the pro-
cedures ourselves. Thus, electronics entered the
teaching of postgraduate medicine in Iowa, and
we found it very effective as well as interesting.

Wednesday, we brushed up on our pediatrics,
covering mainly the period when children are in
the “infant” classification, shortly after birth.

“Neurological Examination of the Neonate” by
Drs. J. C. MacQueen and Hans Zellweger, remind-
ed me of a group of things that I personally may
have been overlooking in examinations of babies
during the newborn period, when the defects — if
present — should be discovered.

Thursday, the general practitioners’ old friend,
Dr. W. C. Keettel, chairmanned talks and confer-
ences on our common obstetric and gynecologic
problems. Many subjects were reviewed and pre-
sented in a new light to the family doctor, to help
him provide better care for the mothers in his
practice. Thursday evening, the annual banquet
was held at the Elks Club, with the junior and
senior medical students and the participating fac-
ulty members as guests of the Iowa Chapter and
of Marion Laboratories. Three hundred attended
the banquet and heard a very interesting and stim-
ulating talk by General James P. Cooney, vice
president for medical affairs of the American Can-
cer Society.

On Friday, the last day, the program was con-
ducted by the faculty of the Department of Inter-
nal Medicine, and it held most of the visiting doc-
tors until the end of the last hour. The subjects
discussed were again the family doctor’s daily
problems in diagnosis and therapy — this time of
the cardiac, the diabetic and the “family plagues
of boils.”

I have touched on only some of the highlights
that particularly interested me. Another person
would probably be as enthusiastic about subjects
that I haven’t mentioned but which were likewise
presented.

- — John D. Conner, M.D., Nevada

COME TO THE
IOWA ACADEMY'S PARTY

Des Moines Room, Hotel Savery
Cocktails 6-8 p.m.

All general practitioners and their wives are welcome.
Tickets will be $1 per person.

249

STATE DEPARTMENT OF HEALTH

Morbidity Report for Month of
February, 1962

Diseases 1

1962

Feb.

1962

Jan.

1961

Feb.

Most Cases Reported
From These Counties

Diphtheria

Scarlet fever

395

304

365

Jefferson, Johnson, Kos-

Typhoid fever

suth, Polk, Woodbury

Smallpox

Measles

620

382

402

Buchanan, Buena Vista,

Whooping cough

Crawford, Polk
Kossuth

Brucellosis

Scott, Washington

Chickenpox

303

446

1,073

Dubuque, Polk, Scott,

Meningococcic

meningitis

Story

Scott

Mumps

259

253

608

Clay, Polk, Story

Poliomyelitis

Des Moines

Infectious

hepatitis

178

199

195

Floyd, Johnson, Polk

Rabies in animals

Mahaska, O'Brien,

Malaria

Washington

Psittacosis

Q fever

Tuberculosis

For the state

Syphilis

109

For the state

Gonorrhea

1 14

For the state

Histoplasmosis

Wapello

Food intoxication

Meningitis (type
unspecified )

Jasper, Polk

Diphtheria carrier

Aseptic meningiti

s 0

Salmonellosis

Boone

Tetanus

Chancroid

Encephalitis (type
unspecified )

H. influenzal
meningitis

Grundy

Amebiasis

Boone, Johnson

Shigellosis

Influenza 14,576

7,858

Outbreak was statewide

Typhoid Fever Cases and Carriers
Iowa — 196 1

Only five cases of typhoid fever have been re-
ported as having occurred in Iowa during 1961.
Upon investigation, including the making of lab-
oratory tests, six cases originally reported as ty-
phoid fever proved to have been salmonella infec-
tions. Diagnoses of four of the true typhoid fever
cases were made on the basis of clinical findings
and laboratory serologies. In the other case, the
typhoid organism was isolated.

Two new typhoid carriers were found. One of
them was identified when the organisms were
grown from the gallbladder contents following
cholecystectomy. In this instance, repeated cul-
tures— the first of them taken 14 or more days
following the last administration of antibiotics —
have all proved to be negative. The second car-
rier is an 87-y ear-old man who has a history of
having had typhoid fever in 1898, during the
Spanish- American War. Since the incidence level
of the disease was so high among U. S. troops at
that time, there is little doubt that the illness
which this man says he had was typhoid fever.
He was hospitalized in 1961 because of a typhoid-
like illness. The original diagnosis was “typhoid
fever with convalescent carrier condition.” Six
months after release from the hospital, this man
continues to be repeatedly positive for typhoid or-
ganisms, phage type D7. The physicians who
studied the case still hold some doubt as to
whether the illness may actually have been ty-
phoid. If it were not, then it is arguable that
the patient had probably continued to be a car-
rier following his recovery from his illness in
1898. Our investigations of his family and other
contacts have failed to bring to light any cases of
the disease for which he might have been a car-
rier source. If he actually retained the infection he
acquired in 1898, he probably is one of the longest
continuous typhoid-fever carriers in the United
States.

Iowa’s previous record for longevity of a ty-
phoid carrier was that of another Spanish-Amer-
ican War soldier. While still ill with the disease,
he had been returned from Cuba to his home in
Illinois. Later, with his family, he had moved to
Iowa, and prior to the middle ’30’s when he was
found to be a carrier, he probably had been re-
sponsible for several cases of typhoid fever in his

250

Vol. LII, No. 4

Journal of Iowa Medical Society

251

family and among his other immediate contacts.
He died in 1948.

Iowa’s typhoid carrier registry contains a total
of 52 names. Members of the state and local health
departments plan to visit each of those persons at
least once a year. In some instances, visits are
made much more often. Most of the carriers are
in the older age groups. Because of their age, they
have a tendency to shun or to disregard their re-
sponsibilities, and it frequently is very difficult to
acknowledge their duty to help prevent a spread
of the infection. In many instances it is necessary
for the health department representatives to work
through a younger, more responsible family mem-
ber. Many of the elderly carriers are becoming
residents in nursing homes or are requiring peri-
ods of hospital care. At any time when a typhoid
carrier is given attention at any institution, it is
necessary that the persons in charge know that he
is a typhoid carrier.

1961 SUMMARY

Total Carriers ....... 52

Questionable 2

Discovered in 1961 2

Median Age 70

Age Range 42 to 95

Age Groups

40-49 5

50-59 6

60-69 14

80-89

90-99

Summary of 1961 Fort Dodge Virus
Outbreak Identified as Coxsackie B-

The Public Health Service Communicable Dis-
ease Center Laboratories at Kansas City has just
reported to the Iowa State Department of Health
on its nearly completed laboratory studies made
on specimens collected last summer from 262 per-
sons in the Fort Dodge area. The virus that caused
the illness has been identified, in those studies at
Kansas City, as Coxsackie B5.

The outbreak that was studied began about
the last week in July, reached its peak at the end
of August, and subsided during the month of
September. The illness consisted of sore throat,
fever, headache, muscle aches, pains, abdominal
cramps, chills, nausea and vomiting. In about 10
per cent of the cases, there was stiff neck, dizzi-
ness and extreme weakness. Although the major-
ity of patients were severely ill for just two or
three days, a few were hospitalized. From the large
studies made last summer by personnel from the
Public Health Service, the State Department of
Health, local health groups and volunteers, it was
shown that in families in which a case occurred,

56 per cent of the other family members contracted
the illness. Seventy-two per cent of the cases oc-
curred in the 1-14 yr. age group, and the greatest
frequency of cases was in the 5-9 yr. age group.
There was an incubation period of between two
and five days.

A breakdown of the report just received from
Kansas City shows that from 262 different per-
sons who submitted specimens for examination,
the Coxsackie B5 virus was found in specimens
from 51 of them. Since the infection was not
limited to Fort Dodge but also occurred in per-
sons living in the surrounding area, specimens
were obtained from cases in other towns as well.
Specimens from three persons in Humboldt, from
four in Gilmore City and from three in Dakota
City were among the 51 that were found to be
positive for the virus. The remaining 41 positive
isolations were from persons with Fort Dodge
addresses. Although most of the virus studies un-
dertaken last August by the Public Health Service
Laboratories at Kansas City have been completed,
work is continuing on a small group (seven) of
as yet unidentified viruses.

Though it is definite, from the large numbers
of isolations, that Coxsackie B-, was the causative
organism, five isolations of Coxsackie BL» were
made from specimens collected in the area. Two
were from members of a family in Lehigh, and the
remaining three were from a family in Fort Dodge.
One isolation of Coxsackie B4 was made from a
Fort Dodge resident. These findings are to be
interpreted as representing a few cases of other
varieties of Coxsackie infection occurring at the
same time. A parallel situation would be the oc-
currence of a few cases of scarlet fever during a
measles outbreak.

Although it was originally assumed that the out-
break was probably due to a Coxsackie virus, it
was a bit surprising that the causative organism
was found to have been Coxsackie B5. We had
previously studied and reported upon a large
outbreak at Mason City in 1956, and upon a
smaller outbreak of the same illness at Fort Dodge
later during that same year. The clinical histories
in the 1956 outbreaks were different. The patients
were more acutely ill. The original diagnosis in
many of the 63 Mason City cases hospitalized at
the beginning of the outbreak was “non-paralytic
poliomyelitis.” The patients’ chief complaints were
severe headache, stiff neck and fever. The fever
was uniformly present, and was characteristically
of the remitting type, with daily spikes to between
99° and 105°F., and lasted from one to 16 days,
with a median of seven days.

The outbreak last summer was studied as a
part of the “around the year” virus surveillance
plan for the Fort Dodge community. The public
response at that time was fine, when people were
requested to cooperate in the intensive study.
Their interest is continuing.

The current aspect of the study includes weekly
collections of nose and throat cultures taken on a

252

Journal of Iowa Medical Society

April, 1962

random-sampling basis by school nurses from
youngsters in the Fort Dodge schools. Those, along
with additional specimens collected by physicians,
are sent periodically to the Public Health Service
Laboratories at Kansas City for identification of

any types of virus that may be present in the area
during the winter months. The work continues
under the direction of health officials from the
Public Health Service, the State Department of
Health and the City of Fort Dodge.

Tuberculosis — New Cases
Iowa — 196 1

Counties Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Total

Allamakee

Appanoose

Audubon

Blackhawk

1 3

2 1

Boone

1 5

Bremer

Buchanan

Buena Vista

Calhoun

Cass

Cedar

1 2

Cerro Gordo

Cherokee

Chickasaw

Clarke

Clay

Clayton

Clinton

1 5

Dallas

Davis

Decatur

1 3

Delaware

Des Moines

2 1

Dubuque

1 2

1 1 1

Emmet

Fayette

Floyd

Greene

Guthrie

Hamilton

Hancock

Hardin

Harrison

Henry

1 4

Humboldt

Jackson

Vol. LII, No. 4

Journal of Iowa Medical Society

253

Counties

Jan.

Feb.

Mar.

Apr.

May

June

July

Aug.

Sept.

Oct.

Nov.

Dec.

Total

Jasper

Jefferson

Johnson

Jones

Kossuth

Lee

Linn

Louisa

Madison

Mahaska

Marion

Marshall

Mills

Monona

Monroe

Montgomery

Muscatine

O'Brien

Osceola

Page

Palo Alto

Polk

Pottawattamie ......

Sac

Scott

Shelby

Sioux

Story ...

Tama

Taylor

Union

Wapello

Warren

Washington

Wayne

Webster

Winnebago

Winneshiek

Woodbury

1961 TOTAL

300

I960 TOTAL

444

REACTIVATED CASES, 1960—38
REACTIVATED CASES, 1961 — 19

Division of Tuberculosis Control, January 20, 1962.

COUNTY MEDICAL SOCIETY OFFICERS

COUNTY

PRESIDENT

SECRETARY

DEPUTY COUNCILOR

Adair

Adams

Allamakee

Appanoose

Audubon

Benton

Black Hawk

Boone

Bremer

Buchanan

Buena Vista

Butler

Calhoun

Carroll

Cass

Cedar

Cerro Gordo

Cherokee

Chickasaw

Clarke

Clay

Clayton

Clinton

Crawford

Dallas-Guthrie

Davis

Decatur

Delaware

Des Moines

Dickinson

Dubuque

Emmet

Fayette

Floyd

Franklin

Fremont

Greene

Grundy

Hamilton

Hancock -Winnebago

Hardin

Harrison

Henry

Howard

Humboldt

Ida

Iowa

Jackson

Jasper

Jefferson

Johnson

Jones

Keokuk

Kossuth

Lee

Linn

Louisa

Lucas

Lyon

Madison

Mahaska

Marion

Marshall

Mills

Mitchell

Monona

Monroe

Montgomery

Muscatine

O'Brien

Osceola

Page

Palo Alto

Plymouth

Pocahontas

Polk.

Pottawattamie

Poweshiek

Ringgold

Sac

Scott

Shelby

Sioux

Story

Tama

Taylor

Union

Van Buren

Wapello

Warren

Washington

Wayne

Webster

Winneshiek

Woodbury

Worth

Wright

L. H. Ahrens, Fontanelle A. S. Bowers, Orient A. J. Gantz, Greenfield

C. L. Bain, Corning J. C. Nolan, Corning J. C. Nolan, Corning

R, H. Palmer, Postville L. B. Bray, Waukon C. R. Rominger, Waukon

R. R. Edwards, Centerville C. F. Brummitt, Centerville E. A. Larsen, Centerville

H. K. Merselis, Audubon R. L. Bartley, Audubon H. K. Merselis, Audubon

0. A. Dutton, Van Horne P. J. Amlie, Blairstown N. C. Knosp, Belle Plaine

G. D. Phelps, Waterloo d. M. Wicklund, Waterloo C. D. Ellyson, Waterloo

N. G. Dennert, Boone J. C. Sutton, Boone R. L, Wicks, Boone

E. H. Stumme, Denver J. W. Rathe, Waverly R. E. Shaw, Waverly

'J. L Hersey, Independence R. K. White, Independence P. J. Leehey, Independence

V. E. Erps, Storm Lake E. R. Blue, Storm Lake R. R. Hansen, Storm Lake

B. V. Andersen, Greene F. F. McKean, Allison F. F. McKean, Allison

P. W. Van Metre, Rockwell City..L. M. Karp, Lake City G. S. Rost, Lake City

C. A. Fangman, Carroll H. L. Skinner, Carroll J. M. Tierney, Carroll

E. M. Juel, Atlantic J. D. Weresh, Atlantic E. M. Juel, Atlantic

H. E. O’Neal, Tipton O. E. Kruse, Tipton H. E. O'Neal, Tipton

R. G. Berggreen, Mason City A. E. McMahon, Mason City H. G. Marinos, Mason City

H. C. Ellsworth, Cherokee D. C. Koser, Cherokee H. J. Fishman, Cherokee

J. D. Caulfield, New Hampton. .. -C. W. Clark. Nashua M. J. McGrane, New Hampton

G. B. Bristow, Osceola E. E. Lauvstad, Osceola H. E. Stroy, Osceola

F. D. Edington, Spencer Eunice M. Christensen, Spencer.. C. C. Jones, Spencer

E. M. Downey, Guttenberg R. H. Shepherd, Monona P. R. V. Hommel, Elkader

J. H. Taylor, Clinton A. L. Jensen, Clinton V. W. Petersen, Clinton

R. M. Johnson, Denison J. M. Hennessey, Manilla R. A. Huber, Charter Oak

C. S. Fail, Adel A. M. Cochrane, Perry A. G. Felter, Van Meter (D)

W. A. Seidler, Jamaica (G)

J. R. Mincks, Bloomfield P. T. Meyers, Bloomfield H. J. Gilfillan, Bloomfield

T. R. Viner, Leon E. E. Garnet, Lamoni E. E. Garnet, Lamoni

W. J. Willett, Manchester R. L. Waste, Manchester R. E. Clark, Manchester

R. D. Rowley, Burlington W. C. Zabloudil, Burlington R. B. Allen, Burlington

D. F. Rodawig, Jr., Spirit Lake..R. J, Coble, Lake Park E. L. Johnson, Spirit Lake

R. D. Storck, Dubuque E. V. Conklin, Dubuque R. J. McNamara, Dubuque

R. M. Turner, Armstrong R. P. Bose, Estherville R. L. Cox, Estherville

H. H. Wolf, Elgin D. A. Freed, West Union A. F. Grandinetti, Oelwein

H. A. Tolliver, Charles City C. L. Kelly, Jr., Charles City....E. V. Ayers, Charles City

W. W. Taylor, Sheffield D. K. Benge, Hampton W. L. Randall, Hampton

A. R. Wanamaker, Hamburg K. D. Rodabaugh, Tabor

A. A. Knosp, Paton G. F. Canady, Jefferson E. D. Thompson, Jefferson

E. A. Reedholm, Grundy Center.. W. H. Verduyn, Reinbeck E. A. Reedholm, Grundy Center

D. C. Anderson, Stanhope E. F. Brown, Webster City G. A. Paschal, Webster City

S. M. Haugland, Lake Mills P. J. Melichar, Garner J. R. Camp, Britt

H. E. Gude, Iowa Falls F. N. Cole, Iowa Falls L. F. Parker, Iowa Falls

F. G. Sarff, Logan R. G. Wilson, Missouri Valley A. C. Bergstrom, Missouri Valley

Mary P. Couchman, Mt. Pleasant. H. M. Readinger, New London . . J. S. Jackson, Mt. Pleasant

^bner Buresh, Lime Springs W. K. Dankle, Cresco P. A. Nierling, Cresco

J. H. Coddington, Humboldt Beryl F. Michaelson, Dakota City.i. T. Schultz, Humboldt

J. W. Martin, Holstein J, B. Dressier, Ida Grove J. B. Dressier, Ida Grove

C. G. Wuest, Amana I. J. Sinn, Williamsburg C. F. Watts, Marengo

O. L. Frank, Maquoketa L. B. Williams, Maquoketa L. B. Williams, Maquoketa

M. R. Moles, Newton L. H. Koelling. Newton J. W. Ferguson, Newton

K. H. Strong, Fairfield J. H. Turner, Fairfield J. W. Castell, Fairfield

R. A. Wilcox, Iowa City A. C. Wise, Iowa City L. H. Jacques, Iowa City

E. H. DeShaw, Monticello T. R. Dolan, Monticello L. D. Caraway, Monticello

J. S. Hooley, Sigourney R. G. Gillett, Sigourney R. G. Gillett, Sigourney

J. M. Rooney, Algona D. F. Koob, Algona

R. E. Murphy, Fort Madison Sebastian Ambery, Keokuk G. H. Ashline, Keokuk

G. C. McGinnis, Ft. Madison

R. M. Wray, Cedar Rapids S. T. Moen, Cedar Rapids H. J. Jones, Cedar Rapids

J. H. Chittum. Wapello L. E. Weber, Jr., Wapello E. S. Groben, Columbus Junction

H. D. Jarvis, Chariton R. E. Anderson, Chariton A. L. Yocom, Chariton

H. H. Gessford, George S. H. Cook, Rock Rapids S. H. Cook, Rock Rapids

G. J. Anderson, Winterset E. G. Rozeboom, Winterset J. E. Evans, Winterset

D. K. Campbell. Oskaloosa L. J. Grahek, Oskaloosa R. L. Alberti, Oskaloosa

G. M. Arnott, Knoxville Stewart Kanis, Pella D. H. Hake, Knoxville

M. E. Jeffries, Marshalltown W. T. Shultz, Marshalltown R. C. Carpenter, Marshalltown

W. A. DeYoung, Glenwood W. A. DeYoung, Glenwood M. L. Scheffel, Malvern

T. E. Blong, Stacyville W. E. Owen, St. Ansgar T. E. Blong, Stacyville

L. A. Gaukel, Onawa W. P. Garred, Onawa L. A. Gaukel, Onawa

H. J. Richter, Albia D. N. Orelup, Albia D. N. Orelup, Albia

Oscar Alden, Red Oak E. L. Croxdale, Villisca H. E. Bastron, Red Oak

E. R. Wheeler, Muscatine Samuel Bluhm. Muscatine K. E. Wilcox, Muscatine

K. W. Myers, Sheldon A. D. Smith, Primghar E. B. Getty, Primghar

H. B. Paulsen, Harris J. H. Thomas, Sibley F. B. O’Leary, Sibley

W. G. Kuehn, Clarinda K. V. Jensen, Clarinda K. J. Gee, Shenandoah

C. C. Moore, Emmetsburg L. C. Wigdahl, Emmetsburg H. L. Brereton, Emmetsburg

J. M. Gacusana, Akron F. C. Bendixen, Le Mars R. J. Fisch, Le Mars

E. O. Loxterkamp, Rolfe H. L. Pitluck, Laurens

M. T. Bates, Des Moines R. J. Reed, Des Moines J. G. Thomsen, Des Moines

G. H. Pester, Council Bluffs D. T. Stroy, Council Bluffs G. H. Pester, Council Bluffs

J. R. Parish, Grinnell B. Grimmer, Grinnell S. D. Porter, Grinnell

D. E. Mitchell, Mount Ayr D. E. Mitchell, Mount Ayr

John Hubiak, Odebolt C. A. Stratman, Sac City J. W. Gauger, Early

A. B. Hendricks, Davenport J. L. Kehoe, Davenport Erling Larson, Davenport

G. E. Larson, Elk Horn T. S. Hutcheson, Harlan J. H. Spearing, Harlan

K. R. Swanson, Hull T. E. Kiernan, Sioux Center M. O. Larson, Hawarden

M. A. Johnson, Nevada Ralph Jensen, Ames J. D. Conner, Nevada

A. J. Havlik, Tama C. W. Maplethorpe, Jr., Toledo.. A. J. Havlik, Tama

R. W. Boulden, Lenox R. W. Boulden, Lenox R. W. Boulden, Lenox

J. L. Beattie, Creston H. J. Peggs, Creston H. J. Peggs, Creston

Kiyoshi Furumoto, Keosauqua . . . . J. T. Worrell, Keosauqua Kiyoshi Furumoto, Keosauqua

E. W. Ebinger, Ottumwa R. P. Meyers, Ottumwa L. J. Gugle, Ottumwa

Amalgamated With Polk County..

E. D. Miller, Wellman E. J. Vosika, Washington G. E. Montgomery, Washington

K. R. Garber, Corydon C. N. Hyatt, Corydon D. R. Ingraham, Sewal

J. R. Kersten, Fort Dodge C. L. Dagle. Fort Dodge C. J. Baker, Fort Dodge

J. A. Bullard. Decorah E. F. Hagen, Decorah E. F. Hagen, Decorah

E. H. Sibley, Sioux Citv R. C. Larimer. Sioux City D. B. Blume, Sioux City

R. L. Olson, Northwood W. G. McAllister. Manly C. T. Bergen, Northwood

A. L. Pitcher, Belmond R. F. McCool, Clarion S. P. Leinbach, Belmond

254

Physicians and Their Wives Can Help Farm People

Identify and Solve Rural Health Problems

All of us want farm people and the staffs of the
organizations which serve them to feel that doc-
tors and their wives are interested in the mainte-
nance of rural health and are anxious to help in
eliminating threats to it whenever they arise.
The Iowa Medical Society’s Rural Health Com-
mittee, composed of doctors from each of 11 sec-
tions of the state, is working with the state groups
that have been set up to serve farm communities,
and with the AMA Council on Rural Health. In
addition, the Woman’s Auxiliary to the Iowa Med-
ical Society and many of its county components
have set up rural health committees to give as-
sistance wherever possible.

Within the past two months, the IMS Rural
Health Committee has mapped out some avenues
for cooperation between farm families and their
doctors, but implementation must take place at
the local level, and the success of the actual pro-
grams will depend upon the initiative of the rural
people themselves, and of the agricultural exten-
sion workers, the county medical societies and the
local Auxiliaries.

The Cooperative Extension Service in Agricul-
ture and Home Economics has in each Iowa Coun-
ty a field staff that includes — ideally, at least — a
county agent, a home economist and a county ex-
tension assistant or associate who works with
youth groups. In addition, there are supervisors
for each of those three sorts of personnel in each
of six geographic areas.

The Ag. Extension, as it is usually called, ad-
vises and assists community groups of many sorts.
Some of them come together more or less tem-
porarily to study topics in conservation, agricul-
tural production and marketing, but othei’s of the
groups are concerned with developing community
leaders, improving family life and providing youth
activities, and continue from year to year. These
latter sometimes undertake to deal with health
matters.

LIAISON NEEDED IN EVERY PART OF THE STATE

At a meeting in Ames on January 23, 1962, the
IMS Rural Health Committee and staff members
of the Ag. Extension Service agreed that local
medical societies and their Auxiliaries should be
asked to meet with the extension workers in
their respective counties, for exchanges of ideas
on the health needs of their communities and on
how to fill them.

One important project on which physicians and
their wives can begin cooperating with extension
workers and the groups that they advise is im-
munization against tetanus. As all of us know, the
emergency protection against tetanus is both more
dangerous and less certain than is the long-term
protection, but emergency protection is frequently
necessary, nowadays, because so many people
have allowed their immunity to lapse. Since farm
family members perhaps sustain cuts and scratches,
if not more serious injuries, more frequently than
do other people, tetanus immunization is a true
rural health need.

The Ag. Extension staff at Ames asked that a
doctor in each county be designated as the phy-
sician whom farm groups can call upon to present
statistics on the tetanus hazard and to explain the
preferability of long-term protection against the
disease. If the county medical societies will make
such appointments, the IMS headquarters will
supply some of the pertinent literature and figures
for them to use.

After starting a county-wide tetanus immuniza-
tion program, doctors and their wives doubtless
will think of other activities for which their com-
munities are in need, but here are a few sugges-
tions. They might help popularize the idea of “a
family doctor for every farm family.” They might
aid in getting people to enroll for the newly-
launched Medical Self-Help Training Program,
which is designed to enable potentially isolated
family groups to treat their injured following a
nuclear attack or some other disaster. And they

might help recruit both farm and town young peo-
ple for medical or paramedical careers. For this
last-named project, the IMS is prepared to furnish
numerous booklets and pamphlets, but direct con-
tacts between the young men and women and the
practicing physicians and their wives is sure to
be most effective.

NEW TASKS FOR THE IMS COMMITTEE

The Ag. Extension executive asked at the Jan-
uary meeting for materials with which farm
youths can be taught good posture, and the Com-
mittee agreed to have a teaching film made for that
purpose. Another of their requests was for help
in planning and presenting health programs at the
summer camp for 4-H Club members that has
been established near Ames. Still another was for
data with which youngsters can be shown that
normality in any of several aspects of physical
development is a range of figures rather than just
one, for juveniles of any particular age.

IMS COOPERATION WITH THE AMA COUNCIL ON
RURAL HEALTH

To stimulate interest in rural health work and
to publicize some of the problems that should be
solved, the Iowa Medical Society will act as host
for an AMA Regional Conference on Rural Health
in Des Moines next month. As the following pro-
gram shows, the speakers will be outstanding ones,
and their messages will contain still more ideas on
how physicians and farm people can work to-
gether in making America an even better place
in which to live.

As a physician or as a physician’s wife, you can
aid in this endeavor by attending the conference,
and you can help even more by bringing several
of your public spirited friends with you.

Remember the place and dates — Hotel Savery,
Des Moines, May 18 and 19 — and if you will need
hotel or motel reservations, apply for them
promptly.

THIRD AMA REGIONAL RURAL HEALTH CONFERENCE
Theme: ‘'Good Rural Health — Our Nation's Wealth"

Friday Morning Session, May 18
Grand Ballroom, Savery Hotel

8: 00 a.m. registration (No registration fee)

10: 00 invocation — The Reverend Edward W.

O’Rourke, Des Moines, Executive Direc-
tor of the National Catholic Rural Life
Conference

10:05 greetings — G. H. Scanlon, M.D., Iowa City,

President of the Iowa Medical Society
10: 10 “Purpose of the Conference” — Samuel P.

Leinbach, M.D., Belmond, Member of the
AMA Council on Rural Health
10: 25 “Good Rural Health — Our Nation’s Wealth”
— Mr. Howard E. Hill, Des Moines, Mem-
ber of the Board of Directors of the
American Farm Bureau Federation, and
President of the Iowa Farm Bureau Fed-
eration

11:00 “Medical Self-Help Training” — Mr. James
D. Clark, Atlanta, Georgia, Chief of the

Medical Self-Help Training Section,
U.S.P.H.S. Division of Health Mobiliza-
tion

11:30 DISCUSSION PERIOD

12:00 RECESS FOR LUNCHEON

Friday Afternoon Session, May 18
Grand Ballroom, Savery Hotel
2:00 p.m. panel discussion: “Quacks, Medicine and
the Law”

Mr. Alfred Barnard, Director, Kansas
City District, U. S. Food and Drug Ad-
ministration

Mr. Oliver Field, Chicago, Director of the
AMA Department of Investigation
3:00 discussion period

3: 45 “Animal Diseases That Endanger Human

Health” — William A. Hagen, D.V.M.,
Ames, Director of the National Animal
Disease Laboratory
4: 15 discussion period

4: 30 “Poison Dangers on the Farm” — Clyde M.

Berry, Ph.D., Iowa City, Member of the
Staff of the S.U.I. Institute of Agricultural
Medicine

5:00 discussion period

Friday Evening Session, May 18
Terrace and Des Moines Rooms, Savery Hotel
7:00 p.m. banquet

invocation— The Reverend C. W. Tompkins,
Fort Dodge, Executive Director, Friend-
ship Haven Home for the Aged
INTRODUCTION OF SPECIAL GUESTS
GREETINGS

The Honorable W. L. Mooty, Lieutenant
Governor of Iowa

Mrs. Harlan English, Danville, Illinois,
President of the Woman’s Auxiliary to
the American Medical Association
“Medicine’s Mission in a Changing Cul-
ture”— The Reverend Robert Varley,
Th.D., Rector of Salisbury Episcopal
Church, Salisbury, Maryland

Saturday Morning Session, May 19
Grand Ballroom, Savery Hotel

9:00 a.m. panel discussion: “Health Insurance — -Poli-
cies, Principles, Procedures and Pay-
ments”

Mr. James E. Bryan, of Bryan and Nor-
ris Medical Administrators, New York
City

Mr. Frank Sullivan, Topeka, Commission-
er of Insurance for the State of Kansas
Mr. E. J. Faulkner, Lincoln, Nebraska,
President of Woodman Accident and
Life Company
10: 00 discussion period

10:40 “The Illinois Student Medical Loan Pro-

gram”— Mr. Roy E. Will, Bloomington, Il-
linois, Assistant Secretary of the Illinois
Agricultural Association
11:10 DISCUSSION PERIOD

11:30 summary of the conference— Marvin A. An-

derson, Ph.D., Ames, Associate Director,
Agricultural Extension Service, Iowa
State University
12: 00 adjournment

THE DOCTOR'S BUSINESS

Ten Rules for Successful
Investing

HOWARD D. BAKER
Waterloo

For most people, investing is a secondary activ-
ity to which they devote much less time and atten-
tion then they give to their principal business or
profession. Consequently, they accord it much
less time and study than it deserves and needs.
The beginner needs to learn the rules for invest-
ing, and even those who have been in the market
for years will find it worthwhile to review them
periodically.

For the “average” investor who has neither the
time nor the inclination to learn the basic princi-
ples and to follow the market closely, the invest-
ment fund is by far the most logical instrumental-
ity. But for a man who already has substantial ac-
cumulations and feels that he has the required skill
and sufficient time for buying and selling individ-
ual stocks and bonds, the following are a few basic
investment precepts:

1. One should make every investment decision
conform to his specific needs. A young investor
with a high earning power is justified in assuming
a reasonable degree of risk, but an older man with
a lower earning power must look primarily for
safety of capital. Each of these men, of course,
must keep his program in tune with our changing
economy. For example, even the older, more con-
servative investor must keep a stake in variable-
dollar investments (common stocks) to assure
maintenance of his purchasing power as a hedge
against the continuing inflationary trend in our
economy.

2. All investors should minimize risk as much
as possible. Dollar-averaging (i.e., the investment
of unvarying sums in one or several particular
equities at regular intervals) , balancing invest-
ments between fixed and variable equities, and
restricting stock purchases to “quality” issues are
good ways of accomplishing this objective.

3. Adequate diversification should be main-

Mr. Baker is a partner in Professional Management Mid-
west, and manager of its Retirement Planning Department.

lyajored in accounting and business administration at
S.U.I., and was an agent of the U. S. Bureau of Internal
Revenue for 3 12 years before forming his present association
in 1953.

tained at all times. Since it is scientifically impos-
sible to select one, two or even three issues best
suited to capital growth, broad industry diversifi-
cation improves the investor’s chances of maintain-
ing a quality portfolio that will achieve reasonable
profits.

4. Holdings should be geared to economic con-
ditions. For example, bonds of distant maturity
should be avoided in times of rising interest rates,
but are excellent purchases when rates are stead-
ily declining. When business is receding, staple,
nondurable goods are best, and during boom peri-
ods, more cyclical, durable and capital goods offer
the greater potential.

5. One should make an effort to anticipate gen-
eral market trends. This can never be done with
precision, but regardless of one’s objectives, he
should reduce his holdings in volatile common
stocks when price-earnings multiples are such as
to make it seem that the public has grossly over-
estimated the potentials of the issuing firms.

6. Purchase only after thorough investigation,
never on the basis of tips or hunches. Although
the scientific approach is less adventurous, it is
the only sound one.

7. Insofar as is possible, buy when the price is
right. One should compare the prices of the issues
he is considering with those for comparable shares
in the same field and with the market in general.
One shouldn’t buy at a price-earnings ratio that is
considerably higher than that which currently pre-
vails in the market as a whole.

8. No individual issue can be bought and put
away. Keeping abreast of one’s holdings is a con-
stant task. Corporate fortunes change, making to-
day’s most attractive purchase a prime candidate
for sale a few months or a few years later. One
must study the company’s annual and interim re-
ports, and keep in touch with technological and
economic developments.

9. Don’t speculate! No part-time investor, and
few professional speculators, can do it successfully.
Invest for the long term, rather than for unpredict-
able short swings. Margin trading and the pur-

255

256

Journal of Iowa Medical Society

April, 1962

chase of penny stocks or promotional situations
invariably involve losses for the average investor.

10. Be patient! Don’t reach for a stock that has
already enjoyed a sustained rise, and don’t allow
technical market adjustments to panic you into
selling an attractive security. Be realistic in your
expectations. The seasoned investor has learned
to “ride with the tide.” The market is always there,
and if a particular commitment disappoints one’s
expectations, the next one may do better — if he
follows the rules.

The poor results of most individual investment
programs can be attributed directly to a failure to
follow these basic concepts and to the casual ap-
proach that the majority of investors take to the
highly technical task of building an investment
portfolio.

In Memoriam

AUDRA D. JAMES, M.D., 1897-1962

Dr. Audra D. James was born in Clarke County,
Iowa, on May 14, 1897, but he attended high school
in South Dakota, where his family had moved
when he was quite young. Following his gradua-
tion, he spent 18 months in the Army Signal Corps
as a private. On returning home, he enrolled at the
University of South Dakota, where he subsequent-
ly received his bachelor of science degree and com-
pleted the first two years of his medical education.
After a year of teaching, he went to Northwestern
University for his final two years and his medical
degree, and graduated in the top 10 per cent of
his class. He was a member of Phi Chi fraternity.

Dr. James came to Iowa Methodist Hospital, in
Des Moines, for his internship, in 1926-1927, and
afterward was on the staffs of Iowa Methodist,
Iowa Lutheran, Mercy and Broadlawns-Polk
County Hospitals. In 1936 he joined the Naval
Reserve, and beginning in 1941 served on active
duty with the Navy. Two of those years, he spent
at sea as senior medical officer on the seaplane
tender Tangier. Then he resumed his membership
in the Naval Reserve, and stayed in the organiza-
tion until his retirement.

He was a member of the Iowa Obstetrical and
Gynecological Society and of the Medical Forum,
a study club, and was a past president of the Iowa
Methodist Hospital staff.

Dr. James was a man who started numerous
projects, and because of his curiosity and per-
fectionism carried them through to success. Fol-
lowing his internship, he was offered the director-
ship of the Pathology Department at Iowa Method-
ist. Later, he was an assistant to Dr. O. J. Fay.
After several years of surgical training, he went to
the Chicago Lying-In Hospital for training with
Dr. DeLee. Then he was associated with Dr.
F. B. Langdon, of Des Moines, in the practice of
obstetrics. His hard work and his unwillingness to
be satisfied with anything but the best placed him

high in these various fields. Obstetrics posed diffi-
culties for the men who practiced it in those days
— ones with which the younger men in that field
haven’t had to deal. Not the least of these was that
most babies were born at home. That meant more
work and responsibility for the attending phy-
sician, and even though the doctor often went un-
paid in those depression years, Dr. James main-
tained the same high standards of service that had
been characteristic of him. During his career, he
delivered over 6,000 babies.

Dr. James’ career in medicine was very fortu-
nately timed. With the rapid development of new
drugs and the perfecting of various technics, he
had the satisfaction of participating in medical
progress. While I was an interne at Iowa Method-
ist, “Jim” was in the pathology laboratory, pre-
paring some of the first saline solutions to be given
intravenously there. The regimen needed improve-
ment, and he kept working on various aspects of
it, such as the pH of the solution, and as was being
done at other hospitals, he insisted that the talcum
in the rubber tubing had to be thoroughly re-
moved. Eventually, intravenous solutions replaced
the retention enema for fluid replacement. That
was before the familiar glass flask and plastic
tubing of today.

“Jim” was a private in the Army during World
War I, and I never could decide whether it had
been his experiences as a doughboy or just his
insatiable curiosity that put him in the Navy dur-
ing World War II. I suspect that it was the latter.
He had many interests other than medicine, such
as hunting, fishing, woodworking and contacts with
people.

The strain of his practice began to tell on Dr.
James in 1949, and his health was impaired. In
1954, he was forced to quit practice. It was a diffi-
cult step for him to take, but as one might have
expected, he was able to redirect his attention to
pursuits compatible with his physical capabilities.
He passed away suddenly and quietly on Sunday,
January 15, 1962. He died as he had lived, with his
private affairs and business matters in perfect
order.

Ordinarily, the title “doctor” before one’s name
is enough in itself to command respect, but Dr.
James earned the respect of his patients, colleagues
and acquaintances every day that he lived. He was
a gentleman in the strictest sense. He never showed
anger or disdain. He treated his associates with
courtesy. He didn’t have to be pardoned an oc-
casional bitter word, for he never uttered one. On
the other hand, he never was complacent about his
work or about his friends. He had about him a
decorum that touched all the people around him.
He liked people, and because they were aware of
that liking, they liked him in return. His passing,
though not unexpected, was a shock and a sorrow
to everyone who knew him.

— Conan J. Peisen, M.D.

Opposition to King-Anderson

In October, 1960, the Iowa Association of Med-
ical Assistants presented an emergency resolution
to the House of Delegates of the American Associa-
tion of Medical Assistants, meeting in Dallas,
Texas, endorsing the opposition of the American
Medical Association to the Forand Bill for Medical
Aid to the Aged through the Social Security Sys-
tem. The resolution was adopted, and copies of it
were sent to the president of the AMA and to each
state medical society.

The Kerr-Mills Bill, passed by both houses of
Congress and signed by President Eisenhower in
the fall of 1960, enables states to guarantee health
care to all needy and near-needy old people with-
out making federal dependents of all of the elderly.
It allows programs under which recipients of aid
can choose their own doctors, and under which
states can make contributions to the premiums on
elderly people’s health insurance policies, if they
want to. The AMA and the AAMA have gone on
record as endorsing that legislation.

Before sufficient time has elapsed to implement
that plan fully, politicians have proposed another
scheme for providing medical care to all Social
Security beneficiaries, regardless of financial need.
It is the King-Anderson Bill. In August, 1961,
AAMA President Bettye Fisher testified before
the House Ways and Means Committee in Wash-
ington, outlining the reasons why we disapprove
of this method of financing health care for our
senior citizens. The King-Anderson Bill, if adopted,
would be the first step down the garden path to
socialized medicine!

How can we help defeat this legislation? 1. The
Woman’s Auxiliary to the AMA offers medical as-
sistant groups “Operation Coffeecup,” which fea-
tures a recording by Ronald Reagan discussing
socialized medicine and King-Anderson legislation.

2. Your county medical society or its Auxiliary
will be happy to provide a speaker to address your
group on this subject. 3. You can study the issues,
and discuss them with your friends and neigh-
bors and with your employer. 4. You can write to
your senators and congressman, urging them to
vote against the King-Anderson Bill.

In writing, remember these points:

1. Address letters properly. Don’t confuse a Sen-
ator with a Representative. The Iowa Senators are
B. B. Hickenlooper and Jack R. Miller, and should

be addressed as: The Honorable , U. S.

Senator from Iowa, Senate Office Building, Wash-
ington 25, D. C. The Iowa Representatives are:

Fred Schwengel, J. E. Bromwell, H. R. Gross, John
Kyi, Neal Smith, Merwin Coad, B. F. Jensen and
C. B. Hoeven. They should be addressed: The

Honorable , Representative in Congress

from the .... District of Iowa, House Office Build-
ing, Washington 25, D. C.

2. Be local. Tell how your community and your
individual budget would be affected.

3. Be businesslike, and state your request and
the reasons why you are against the proposal.

4. Be brief, polite and reasonable.

5. Be yourself. Use your own words and your
own paper.

6. Be appreciative.

The AMA, 535 North Dearborn Street, Chicago
10, Illinois, has pamphlets opposing King-Ander-
son that it would like to distribute through your
office or organization, and they are available free
of charge. The titles are: “A Family Doctor’s Fight
Against Socialized Medicine,” “Medical Aid for
the Aged,” and “America — Beware of the Welfare
State.”

— Helen G. Hughes

Annual Meeting of the IAMA

The IAMA annual meeting will be held at the
President Hotel, in Waterloo, on May 4, 5 and 6,
1962. In addition to meetings of the Executive Com-
mittee and the House of Delegates, the following
educational program has been arranged:

Saturday, May 5

9:45 a.m.

10:00 a.m.

11:00 a.m.

12:15 p.m.
1:45 p.m.

2:45 p.m.

Invocation

Welcome — Hostess President, Mrs. Sue
Phillips

Greeting — IAMA President, Miss Wan eta
Christensen

film: “Sterilization Procedures in the Med-
ical Office,” courtesy of Wyeth Labora-
tories

panel discussion: Office Procedures That
Concern the Medical Assistant— V. H.
Plager, M.D., moderator

“The Doctor’s Point of View” — C. D. Elly-
son, M.D.

“Personality and the Patient’s Point of
View” — Mrs. Millard Mills

“Laboratory Technics” — Mr. John Chehak
luncheon and style show
“Public Relations” — Dr. Virgil Lagomar-
cino, director of teacher education, Iowa
State University, Ames
“Legal Problems in the Medical Office” —
Mr. Arthur O. Leff, legal adviser for
University Hospitals, Iowa City

257

258

Journal of Iowa Medical Society

April, 1962

6:00 p.m. cocktail hour: Courtesy of Blackhawk

County Medical Society
6:30 p.m. musical treat — The Med-i-cats
7:30 p.m. banquet — T. L. Trunnell, M.D., master of
ceremonies

“Satellites and Space Travel” — Willard J.
Poppy, Ph.D., Science Department, State
College of Iowa, Cedar Falls

Sunday , May 6

12:15 p.m. luncheon

Presentation of Officers
Address — Donovan F. Ward, M.D., Du-
buque

New Cost of Medical Care Booklet

Americans spend more today for medical care
but buy more and better services than ever before.

Even though we’re spending six cents of every
dollar for health, we’re able to purchase health
restoring services that weren’t available at any
price 20 years ago.

An American Medical Association booklet has
just been updated and is being offered now to help
medical assistants explain to patients how some of
the spectacular new technics in medicine are help-
ing Americans live longer and get more from their
health dollars.

Entitled “The ? Cost of Medical Care (1940-
1960),” the booklet points out the following:

• A child born today can expect to live seven
years longer than one born 20 years ago.

• Today new antibiotic drugs prevent pneu-
monia that used to kill one of every three or four
persons it attacked.

• Low cost vaccines today can protect you
against much serious illness.

• The average stay in a hospital today for an
appendectomy is 5V2 days whereas 20 years ago
it would have been at least 14 days.

Another important factor brought out in this
16-page cartoon-style booklet is that physicians’
fees have not risen as much as the prices of many
other goods and services we buy. Between 1940
and 1960, doctors’ fees rose only 95 per cent.

All medical costs are up 115 per cent since 1940,
the booklet says, but food prices are up 150 per-
cent, public transportation has increased 145 per
cent and men’s haircuts are up 233 per cent.

To help pay for today’s super medical care,
Americans are buying more and more voluntary
health insurance.

Latest statistics from the Health Insurance In-
stitute show that for last year 75 per cent of all
Americans and more than 53 per cent of those
over 65 carry health insurance.

As members of the health team, you may be
asked quite frequently about various aspects of
medical care and health insurance. This little
booklet will give you many of the answers you’ll
need.

Furthermore, if you would like to have a few

copies for distribution in your doctor’s office, write
to Special Services Department, American Medi-
cal Association, 535 North Dearborn, Chicago 10,
Illinois.

All-Out Federal Effort to Develop
Cold Vaccines

An all-out effort to develop vaccines against
the widespread respiratory infections — commonly
grouped under the heading “the common cold” —
was announced at the end of February by Surgeon
General Luther L. Terry, of the U. S. Public
Health Service.

The new program will bring together special
facilities and skilled manpower to concentrate on
the development of vaccines for human use, Dr.
Terry said. Small pilot lots of vaccine will be eval-
uated for potency and tested for purity and safety.
After successful preliminary trials, controlled eval-
uation will be extended through field trials. These
steps will develop information on dosage, pre-
ferred methods of administration and technical
improvement. The next step will be the testing of
larger lots on young adults, with the cooperation
of selected military or prison populations, and
later on civilian populations.

The new program will be directed by Dr. Dor-
land J. Davis, associate director of the National
Institute of Allergy and Infectious Diseases. A
Board for Vaccine Development will be headed by
Dr. Gordon Meikeljohn, head of internal medicine
at the University of Colorado, and will include
Dr. Floyd W. Denny, Jr., of the University of
North Carolina; Dr. George G. Jackson, of the
University of Illinois; and Dr. Walsh McDermott,
of Cornell University.

A massive problem in adults, respiratory ill-
nesses are even more pervasive in children. Each
year in the pre-school age group, there are more
than 20,000,000 respiratory episodes with fever. An
estimated 83 per cent of all illnesses between birth
and age 18 are caused by acute respiratory disease,
according to a 30-year study by scientists at Har-
vard.

It is now possible to implicate known viruses in
about 60 per cent of the serious respiratory ill-
nesses of hospitalized children, and it is these
viruses that will receive immediate attention in
the Vaccine Development Program. Priorities have
been set up to make prototype vaccines, both live
and attenuated, with respiratory syncytial virus;
parainfluenza viruses 1, 2 and 3; PPLO-Eaton
agent; and adenoviruses 1, 2, 3, 4, 5 and 7, in that
order of priority. These priorities have been chosen
because RS viruses are believed to cause about
20 per cent of these illnesses; parainfluenza viruses
15 per cent; PPLO-Eaton agent 10 per cent; and
adenovirus 10 per cent. In addition, the possibility
of vaccine development against the enteroviruses
and enterovirus-like agents incriminated in respir-
atory disease of adults will be explored.

WOMAN'S AUXILIARY

to the

IOWA MEDICAL SOCIETY

1962 Annual Meeting , Des Moines

Program Theme: "Speak Your Belief in Deeds"

MRS. BENJAMIN F. KILGORE, Presiding

Sunday, May 13

2:00-4:00 p.m. pre-convention board meeting — East
Room, Hotel Savery — State officers, councilors,
county presidents and committee chairmen

6:30 p.m. dutch treat buffet — Johnny & Kay’s, Fleur
Drive at Leland — ALL board members, conven-
tion committee chairmen and husbands

Monday, May 14

8:00 a.m. to 4:00 p.m. registration — Mezzanine, Ho-
tel Savery

hospitality room — East Room, Hotel Savery — Hos-
tesses: Mrs. C. A. Trueblood, Indianola, District
V, and Mrs. I. K. Sayre, St. Charles, District X —
ALL physicians’ wives welcome!

9:30 a.m. project brunch — Terrace Room, Hotel Sa-
very, honoring Mrs. William G. Thuss, the na-
tional president-elect, past state presidents and
chairmen of standing committees
Hostesses: Presidents of central area auxiliaries
HOUSE OF DELEGATES

Call to order — Mrs. Benjamin F. Kilgore, Des
Moines, president

Invocation — C. T. R. Yeates, D.D., Westminster
United Presbyterian Church, Des Moines
Auxiliary Pledge

“I pledge my loyalty and devotion to the Woman’s
Auxiliary to the American Medical Association.
I will support its activities, protect its reputation
and ever sustain its high ideals.”

Welcome — Mrs. F. C. Coleman, Des Moines, chair-
man of local arrangements
Response — Mrs. A. C. Richmond, Fort Madison,
state president-elect
Presentation of Guests

Convention Announcements — Mrs. N. A. Schacht,
Fort Dodge, area chairman
Convention Rules of Order — Mrs. G. A. Paschal,
Webster City, parlimentarian
Roll Call — Mrs. F. L. Poepsel, West Point, record-
ing secretary

Minutes of 1961 Annual Meeting — Mrs. G. I. Tice,
Mason City, chairman
Report of the President

Reports of Officers and Committee Chairmen
Auditor’s Report — Mrs. J. H. Matheson, Des Moines,
state treasurer

Reports of County Presidents

“Homemaker Service in Polk County” — Mrs. A. B.
Phillips, Des Moines

“Rural Health Program in Iowa” — Mrs. E. A. Lar-
sen, Centerville, regional rural health chairman,
Woman’s Auxiliary to the AMA
memorial service — Mrs. R. L. Wicks, Boone
Nominations for 1963 Nominating Committee, and
Presentation of Election Committee
Election of 1963 Nominating Committee
workshop: “Our Deeds Speak” — Moderator, Mrs.
L. V. Larsen, Harlan, program chairman. Panel
members: Mrs. H. C. Merillat, Des Moines, Mrs.
D. H. King, Spencer, Mrs. W. C. Shinkle, Des
Moines, and Mrs. S. P. Leinbach, Belmond
address — Mrs. William G. Thuss, national presi-
dent-elect

12:30 p.m. Selections from “The King and I” — Pat
Valentine

1:00 p.m. SURPRISE— A FREE AFTERNOON!

Tuesday, May 15

8:00 a.m. to 12 noon registration — Mezzanine, Hotel
Savery

hospitality room — East Room, Hotel Savery

Hostesses: Mrs. I. K. Sayre, St. Charles, District
X, and Mrs. C. A. Trueblood, District V, Indian-
ola

9: 30 a.m. house of delegates

Call to order — Mrs. Benjamin F. Kilgore, president
Roll Call — Mrs. F. L. Poepsel, recording secretary
Presentation of 1962-1963 Budget — Mrs. E. A. Vor-
isek, finance chairman

Election instructions — Mrs. G. A. Paschal, par-
limentarian

Report of Nominating Committee — Mrs. D. C.

Wirtz, Des Moines, chairman
Election of officers

Election of delegates to National Auxiliary Con-
vention

Revisions of Constitution and Bylaws — Mrs. R. E.

Hines, Des Moines, chairman
Resolutions Committee Report— Mrs. E. A. Larsen
Convention Courtesy Resolutions — Mrs. G. I. Tice
New Business

Installation of Officers — Mrs. William G. Thuss, na-
tional president-elect

259

260

Journal of Iowa Medical Society

April, 1962

Report of Registration Committee — Mrs. R. H.
Foss, Des Moines, chairman

11:00 a.m. “Our Auxiliary” — G. H. Scanlon, M.D., Iowa
City, president-elect of the Iowa Medical Society
and chairman of the Woman’s Auxiliary Advi-
sory Committee

Report of the administrative secretary — Mrs. Hazel
T. Lammey

11:30 a.m. Recess

12: 00 noon luncheon — honoring retiring president,
Mrs. Benjamin Kilgore, and 1961-1962 officers —
Terrace Room, Hotel Savery
Mrs. Louis Goldberg, Des Moines, presiding

Table hostesses representing District IX, central
area

Luncheon Invocation — Mrs. Daniel Glomset, Des

Moines, accompanied by

Guests of honor:

O. N. Glesne, M.D., president, Iowa Medical Soci-
ety

G. H. Scanlon, M.D., president-elect, Iowa Medical
Society and chairman of the Auxiliary Advisory
Committee

C. W. Seibert, M.D., member of the Advisory Com-
mittee

J. E. Houlahan, M.D., member of the Advisory
Committee

R. F. Birge, M.D., secretary, Iowa Medical Society
E. R. Annis, M.D., Miami, Florida

D. L. Taylor, executive director, Iowa Medical
Society

Hazel T. Lammey, administrative secretary, Wom-
an’s Auxiliary to the Iowa Medical Society
Mrs. R. A. Anderson, Iowa City, president, Wom-
an’s Auxiliary to the Iowa Chapter Student
American Medical Association
Presidents of Iowa Interprofessional Association
Auxiliaries and other guests
Presentation of Essay Contest Awards — O. N.

Glesne, M.D., president, Iowa Medical Society
Presentation of Volunteer Health Service Award —
Mrs. E. M. Honke, Sioux City, Community Serv-
ice chairman

Inaugural Address — Mrs. A. C. Richmond, Fort
Madison

Presentation of Past President’s Pin — Mrs. J. A.
Downing, Des Moines

2:00 p.m. speaker — Edward R. Annis, M.D., Miami,
Florida

2:30 p.m. black hawk county auxiliary fashion fan-
tasy— Moderator, Mrs. R. F. Nielsen, Cedar Falls

3:00 p.m. adjournment

3:30 p.m. post-convention executive committee meet-
ing, East Room, Hotel Savery

7 : 00 p.m. banquet — Terrace Room, Hotel Savery

9:00 p.m. cadeucus capers — Benefit Dance for the
Woman’s Auxiliary Health Educational Loan
Fund

HOSPITALITY ROOM
Monday — 8:30 A.M. -4:00 P.M.
Tuesday — 8:30 A.M. -12:00 Noon
ALL PHYSICIANS’ WIVES WELCOME

Annual Meeting Guest

Mrs. William Thuss, of Birmingham, Alabama,
was named president-elect of the Woman’s Auxil-
iary to the American Medical Association at the
38th Annual Convention in June, 1961, in New
York City.

Mrs. Thuss has served as president of both her
county and state Auxiliaries. In the National Aux-
iliary, she has just completed a term as first vice-
president and membership chairman and, prior to
that, had served as a regional vice-president.

She has been associated with many civic and
health groups in Birmingham over the years. An
organizer and first president of the Visiting Nurse
Association, she also has been active on the board
of Mercy Home, a child care institution, and the
Jefferson County Coordinating Council.

Among her other activities are a special com-
mittee on juvenile delinquency of Jefferson Coun-
ty Association for Mental Health, education com-
mittee of the local unit of the American Cancer
Society, charter member of the University Hos-
pital Auxiliary, and vice-president of the Radio-TV
Council.

Mrs. Thuss, the former Louise Benedict, was
born in Nashville and graduated from Ward-
Belmont and Vanderbilt University. Dr. Thuss is
in industrial practice. He has devoted his life to
occupational medicine and surgery, and is director
of the Thuss Clinic, which specializes in that field.
Two of their three sons also pursued medical
careers.

The leisure-time activities of Mrs. Thuss in-
clude reading, swimming, fishing and cruising on
the Tennessee River.

Vol. LII, No. 4

Journal of Iowa Medical Society

261

Our President Says —

“It is required of a man that he should take part
in the actions and passions of his times, at the
peril of being judged not to have lived.”

—Justice Oliver Wendell Holmes

We have had an opportunity and a challenge,
these past several months, to indicate to our ac-
quaintances and to our Congressmen that we, as
citizens of the United States, are a dedicated group
of women with a rightful purpose, and are not fear-
ful to express our beliefs or to oppose the King-
Anderson Bill, HR 4222. Why have so many of us
neglected to take a stand? Let’s not deceive our-
selves that we can avoid playing a part in solving
the problems of our times and in preserving our
freedoms. We must express our beliefs, lest we be
judged not to have lived!

Winter in Iowa has been of the old-fashioned
kind, with many inches of snow on the ground
since December, but the warm, sunny days of
April are brightening our outlook. We are looking
forward to the Annual Meeting of the Woman’s
Auxiliary to the Iowa Medical Society, May 14
and 15. You have observed the program highlights
in this issue of the woman’s auxiliary news, and
each of you will want to attend some or all of the
sessions.

Mrs. Wm. G. Thuss, of Birmingham, Alabama,
the president-elect of the Woman’s Auxiliary to
the American Medical Association, will be our na-
tional guest this year, and will bring an enlighten-
ing message to us.

We take pride in welcoming three new county
Auxiliaries and 14 new members-at-large to our
state family. The newly organized county Auxil-
iaries are Dickinson, Marion and Scott. The new
members-at-large are: Mrs. Paul Cunnick, Daven-
port; Mrs. Clyde F. Deal, Elkader; Mrs. John R.
Camp, Britt; Mrs. R. V. Daut, Davenport; Mrs.
A. B. Kuhl, Jr., Davenport; Mrs. D. J. Sheehan,
Cherokee; Mrs. L. S. Miltner, Davenport; Mrs.
R. E. Olsen, Muscatine; Mrs. R. M. Wallace, Al-
gona; Mrs. L. E. Weber, Jr., Wapello; Mrs. J. L.
Ehrenhaft, Iowa City; Mrs. M. L. Mosher, Iowa
City; Mrs. I. K. Sayre, St. Charles; and Mrs. E. E.
Lauvstad, Osceola.

The Health Educational Loan Fund Committee
has announced that our annual benefit dance will
take on a new look this year. Be alert for the new
face!!

You are all cordially invited to attend the 39th
Annual Convention of the Woman’s Auxiliary to
the American Medical Association, in Chicago on
June 25-28, inclusive. Be sure to notify our record-
ing secretary, Mrs. F. L. Poepsel, if you are plan-
ning to attend and would enjoy serving as a dele-
gate. She will present the list of such Auxiliary
members to the House of Delegates on Tuesday,
May 15, and from that list the delegates who are
to represent Iowa will be elected. You can expe-

rience real inspiration for Auxiliary work by at-
tending the National Convention.

The yearly reports from those of you who are
county presidents and district councilors will re-
flect the efforts of the Auxiliaries in your respec-
tive areas. Regardless of how small a group yours
is, it has a responsibility for doing its part. Our
Auxiliary chain is only as strong as are its indi-
vidual links! Let’s each of us help to preserve the
freedom of her husband’s profession!!

Your State Auxiliary officers extend a cordial
invitation to all doctors’ wives to join with them
in making the 1962 Annual Meeting an outstanding
success. I hope to meet many of you at that time.

— Mrs. Benj. F. Kilgore
President

Community Action for Mental Health

This year, Mental Health Month will be ob-
served from April 9 to May 5, with “Community
Action” as the theme. The Woman’s Auxiliary to
the AMA is requesting the cooperation of each
county Auxiliary in every state in focusing the
attention of the public on the problems of mental
health at national, state and local levels.

Since more than 50 per cent of all hospital beds
are occupied by the mentally ill, we as doctors’
wives must assume leadership in meeting this
serious health problem. We should evaluate the
services available in our areas, the progress that
has been made, and the opportunities for further
improvement that can readily be utilized.

This is an excellent time at which to use the
various news media in publicizing the Auxiliary’s
activities in the field of mental health.

The Iowa Mental Health Authority has furnished
the Auxiliary with a new supply of the “Milestones
to Marriage” pamphlets for use in senior high
schools. They may be obtained by addressing re-
quests to me. There is no charge for this series.

Mrs. Selig M. Korson
Mental Health Chairman
P.O. Box No. 11, Independence

In Memoriam

Mrs. Clarence Denser, Sr., a charter member of
the Marion County Auxiliary, passed away at
Mercy Hospital, Des Moines, on February 21, 1962,
following a several months illness. Mrs. Denser
was the mother of Dr. Clarence Denser, Jr., a Des
Moines pathologist. Dr. Clarence Denser, Sr. is a
member of the staff at the Veterans Administra-
tion Hospital in Knoxville.

Help your central office to maintain an ac-
curate mailing list. Send your change of ad-
dress promptly to the Journal, 529-36th Street,
Des Moines 12, Iowa,

262

Journal of Iowa Medical Society

April, 1962

COUNTY AUXILIARIES

MAHASKA

The Mahaska County Medical Auxiliary met on
Tuesday, February 13 for a one o’clock luncheon
at the Downing Hotel. Mrs. Kenneth Lemon pre-
sided at the buisness meeting which followed.

The Auxiliary has been asked to back the “Get-
Out-The Vote” campaign for the Mahaska County
Hospital bond issue.

The Auxiliary adopted a resolution opposing
H.R. 4222 and will forward it to the Iowa senators
and representatives, the members of the House
Ways and Means Committee and other important
contacts.

Our district councilor, Mrs. L. F. Catterson, en-
listed our support for arranging centerpieces and
serving as hostesses for the president’s luncheon at
the Annual Meeting of the Auxiliary in Des Moines
in May.

—Mrs. Ellis Duncan, Secretary

MARION

The Woman’s Auxiliary to the Marion County
Medical Society held a one o’clock luncheon at the
Maple Buffet, Knoxville, on Tuesday, March 6,
1962, with nine members present.

This meeting was held in place of the February
meeting which was postponed due to the weather.
The regular March meeting will be held March 20.

Mrs. D. A. Mater, president, presided at the
business meeting. A letter from Mrs. L. F. Catter-
son, ninth district councilor was read in regard to
the luncheon to be held at the state meeting in
May.

Mrs. Clyde Nicholson, a charter member of the
Marion County Auxiliary moved to her new home
in Des Moines during the latter part of February.
Dr. Nicholson is on the staff at the Veterans Ad-
ministration Hospital in Des Moines.

— Mrs. T. D. Clark, Secretary

MARSHALL

The Marshall County Medical Auxiliary met
March 6 at Stone’s Restaurant, for a dinner and
program. The guest speaker was Dr. Jared Nesset,
a member of the American Association of Ethical
Hypnotists. Miss Garrah M. Packer, a retired
school teacher who has been continuously active

in volunteer Red Cross work for over 40 years, was
named Marshall County’s “Woman of the Year”
in the health field, and her name is being sub-
mitted to the state committee.

Another matter of importance at this meeting
was the action taken to give $15 to each of two
projects, the Health Educational Loan Fund and
the County Mental Health Center.

Mrs. Jack Crandall and Mrs. L. O. Goodman
volunteered to take the pilot series of twelve
lessons in the Civil Defense Program.

Mrs. Rufus Kruse and Mrs. Earl Keyser were
appointed to the nominating committee for the new
year.

The members were given the names and ad-
dresses of their Congressmen, so that they might
write them stating their opposition to health care
for the aged under the social security program as
set out in the King- Anderson bill.

POLK

The Woman’s Auxiliary to the Polk County
Medical Society held a benefit bridge and canasta
party at the Des Moines Golf and Country Club on
February 9, 1962. A dessert luncheon was served
at 1:00 p.m. Pastel-colored hyacinths were given
as table prizes, and they added some spring-like
beauty to the festive occasion. Several door prizes
were also awarded.

About 180 members and guests were welcomed
by our president, Mrs. Donald H. Kast, at this
annual event. Proceeds will be used for the Future
Nurses Clubs in the high schools in Polk County
and for the Auxiliary’s health projects. Mrs. E. A.
Vorisek and Mrs. J. H. Dickens were the co-chair-
men.

CADEUCUS CAPERS

Tuesday, May 15 — Banquet and Dance
Des Moines and Terrace Rooms — Hotel Savery

Benefit Dance for

Woman’s Auxiliary Health Educational Loan
Fund

Evan Morgan’s Orchestra

Standard Medical and Surgical Company
sponsor the social hour from 8:30

WOMAN’S AUXILIARY TO THE IOWA MEDICAL SOCIETY

President — Mrs. B. F. Kilgore, 5434 Woodland, Des Moines 12
President-Elect — Mrs. A. C. Richmond, 1132 Avenue A, Fort
Madison

Recording Secretary— Mrs. F. L. Poepsel, West Point
Corresponding Secretary — Mrs. N. W. Irving, Jr., 4916 Har-
wood Drive, Des Moines 12

Treasurer— Mrs. J. H. Matheson, 4321 California Drive, Des
Moines 12

Editor of the news — Mrs. Herbert Shulman, 101 Martin Road,
Waterloo

/-'■ *>

% > ?

IIOWA MEDICAL SOCIETY

IN THIS ISSUE:

• The Professional Person's Place in Public

Affairs, page 263

• Bell's Palsy, page 269

• Biochemical and Clinical Aspects of

Acetylsalicylic Acid, page 276

• Congenital Megacolon, page 285

• Diagnosis and Treatment of Brain-

Damaged Children, page 287

• The Face of Depression, page 294

U.C. MEDICAL CENTER LIBRARY

MAY 8 1962

San Francisco, 22

ma.

increased-

analgesia

DARVOr COMPOUND-65

Darvon Compound-65 provides twice as much Darvon® as does regular
Darvon Compound without increase in salicylate content or the size of
the Pulvule®. Usual dosage is 1 Pulvule three or four times daily.

Darvon Compound Darvon Compound-65

32 mg Darvon 65 mg.

162 mg Acetophenetidin 162 mg.

227 mg A.S.A.® 227 mg.

32.4 mg Caffeine 32.4 mg.

Darvon® Compound (dextro propoxyphene and acetylsalicylic acid compound, Lilly)

Darvon® (dextro propoxyphene hydrochloride, Lilly)

A.S.A.® (acetylsalicylic acid, Lilly)

This is a reminder advertisement . For adequate information for use, please consult manu-
facturer’s literature. Eli Lilly and Company , Indianapolis 6, Indiana.

220245

IMS ANNUAL MEETING

VETERANS AUDITORIUM, DES MOINES

MAY 13-16, 1962

MAY, 1962

“crying solitary in lonely places ”

DIL

(diphenylhydantoin, Parke-Davis)

permits a richer life for the epileptic

“It has been more than twenty years since the introduction of
diphenylhydantoin sodium (DILANTIN Sodium) as an anti-
convulsant substance . This drug marks a milestone in the
rational approach to the management of the epileptic.”1
In grand mal and psychomotor seizures, DILANTIN is a drug
of choice for a variety of reasons: • effective control of sei-
zures1'9 • oversedation is not a common problem2 • possesses
a wide margin of safety3 • loiv incidence of side effects3 • its use
is often accompanied by improved memory, intellectual per-
formance, and emotional stability.10 DILANTIN (diphenylhy-
dantoin, Parke-Davis ) is available in several forms, including
DILANTIN Sodium Kapseals,® 0.03 Gm: and 0.1 Gm., bottles
of 100 and 1,000. Other members of the PARKE-DAVIS FAMILY
OF ANTICONVULSANTS for grand mal and psychomotor sei-
zures : PHELANTIN ® Kapseals (Dilantin 100 mg., phenobar-
bital 30 mg., desoxyephedrine hydrochloride 2.5 mg.), bottles
of 100. for the petit mal triad: MILONTIN® Kapseals ( phen -
suximide , Parke-Davis) 0.5 Gm., bottles of 100 and 1,000;
Suspension, 250 mg. per 4 cc., 16-ounce bottles. CELONTIN®
Kapseals ( methsuximide, Parke-Davis ) 0.3 Gm., bottles of
100. ZARONTIN® Capsules (etho suximide, Parke-Davis) 0.25
Gm., bottles of 100.

This advertisement is not intended to provide complete information for
use. Please refer to the package enclosure, medical brochure, or write for
detailed information on indications, dosage, and precautions.

REFERENCES: ( l ) Roseman, E.: Neurology II .912, 1961. (2) Bray, P. F.:
Pediatrics 23:i5i, 1959. (3) Chao, D. II.; Druckman, R., & Kellauiay, P.: Con-
vulsive Disorders of Children, Philadelphia, W. B. Saunders Company, 1958,
p. 120. (4) Crawley, J. W.: M. Clin. North America 12:3J7, 1958. (5) Livingston,
S.: The Diagnosis and Treatment of Convulsive Disorders in Children, Springfield,
111., Charles C Thomas, 1954, p. 190. (6) Ibid.: Postgrad. Med. 20 :584, 1956.
(7) Merritt, H. H.: Brit. M. J. 1:666, 1958. (8) Carter, C. II.: Arch. Neurol. &
Psychiat. 7it:136, 1958. (9) Thomas, M. H., in Green, J. R., & Steelman, H. F.:
Epileptic Seizures, Baltimore, The Williams & Wilkins Company, 1956, pp. 37-48.
(10) Goodman, L. S., & Gilman, A.: The Pharmaco-
logical Basis of Therapeutics, ed. 2, New York, The
Macmillan Company, 1955, p. 187, 92462

PARKE-DAVIS

PARKE. DAVIS A COMPANY. Detroit 31, Michigan

CONTENTS

The Professional Person’s Place in Public Affairs:
A Medical School Commencement Address
Walter H. Judd, M.D., Repr. in Congress from

the Fifth District of Minnesota ..... 263

SCIENTIFIC ARTICLES

Bell’s Palsy

Maurice W. Van Allen, M.D., Iowa City . . 269

The Biochemical and Clinical Aspects of Acetyl-
salicylic Acid

W. D. Paul, M.D., and J. I. Routh, Ph.D., Iowa

City 276

A Case Report: Congenital Megacolon (Hirsch-
sprung’s Disease), Associated With Hypopro-
teinemia and Edema

R. G. Berggreen, M.D., Mason City .... 285

Diagnosis and Treatment of Brain-Damaged Chil-
dren at the Child Development Clinic, S.U.I.
Department of Pediatries
Robert B. Kugel, M.D., and Theron Alexander,

Ph.D., Iowa City 287

The Face of Depression

A. S. Norris, M.D., Iowa City 294

State University of Iowa College of Medicine
Clinical Pathologic Conference 297

EDITORIALS

Causes of Death Following Burns ..... 305

New Adverse Reaction to the Tetracyclines . 306

The Guillain-Barre Syndrome . 307

Parental Guidance and Leadership ..... 308

Corrections 308

Orchitis and Infectious Mononucleosis .... 308

SPECIAL DEPARTMENTS

Coming Meetings 303

In the Public Interest Facing Page 312

Journal Book Shelf 313

Iowa Association of Medical Assistants .... 315

The Doctor’s Business 316

Iowa Chapter of the American Academy of General

Practice 317

State Department of Health 318

Woman’s Auxiliary News 320

The Month in Washington xxxi

Personals xxxix

Deaths 1

MISCELLANEOUS

New Booklet on Quackery 267

Organ and Tissue Transplants at AMA Chicago

Meeting 268

Dean of the S.U.I. College of Medicine Resigns . 275

National Blue Shield Statistics 284

AMA Urges School Health Exams 309

The AMA’s New Department of Medicine and

Religion 309

Eradication of Tuberculosis in Children . . . 310

Iowa Medical Society Policy -Evaluation Commit-
tee Report on the National Blue Shield Senior

Citizens Program 311

Selective Service for Physicians xxxii

1961 Lobbying Expense by Labor Unions . . xxxvi

Traffic Accidents and Their Causes — 1961 and 1960 lii

EDITORS

PUBLICATION COMMITTEE

Dennis H. Kelly, Sr., M.D., Scientific Editor Des Moines

Edward W. Hamilton, Ph.D., Managing Editor.

Des Moines

SCIENTIFIC EDITORIAL PANEL

Walter M. Kirkendall, M.D Iowa City

Floyd M. Burgeson, M.D. Des Moines

Daniel A. Glomset, M.D.. Des Moines

Robert N. Larimer, M.D. Sioux City

Daniel F. Crowley, M.D.. Des Moines

Samuel P. Leinbach, M.D Belmond

Otis D. Wolfe, M.D Marshalltown

Cecil W. Seibert, M.D ..Waterloo

Richard F. Birge, M.D., Secretary Des Moines

Dennis H. Kelly, Sr., M.D., Editor Ex Officio Des Moines

Address all communications to the Editor of the Jour-
nal, 529-36th Street, Des Moines 12

Postmaster, send form 3579 to the above address.

Second-class postage paid at Fulton, Missouri, and (for additional mailings)
Iowa Medical Society at 1201-5 Bluff Street, Fulton, Missouri. Editorial Office:
tion Price: $3.00 Per Year.

at Des Moines, Iowa. Published monthly by the
529-36th Street, Des Moines 12, Iowa. Subscrip-

The Professional Person's Place
In Public Affairs

A Medical School Commencement Address

WALTER H. JUDD, M.D.

Representative in Congress From the
Fifth District of Minnesota

It is indeed a great honor and privilege to be in-
vited to speak at the commencement exercises of
the various schools of the College of Medical
Evangelists, which for more than half a century
has been so successfully training men and women
in the healing arts, to serve God and to minister
to the needs of man — both in this state and nation
and throughout the world. You who are being
graduated today will find, I am sure, that your
alma mater has equipped you well with all that
any medical school can give its students of scien-
tific knowledge and technical skills. I have no con-
cern regarding the excellence of your training or
the high quality of your professional abilities. If
there is any reason for concern, it is more likely
to be with regard to the quality of your citizenship.
For that must be of a higher order than my gen-
eration has demonstrated, or there may not long
be a society in which you will have opportunity
to use with success and satisfaction the knowledge
and skills you have worked so long and hard to
acquire here.

Our professions are going through the latest of
several transitions experienced in the last cen-
tury. Originally, the doctor’s main concern was
with therapeutics. Since he didn’t know too much
about disease processes, it really amounted to
treatment of symptoms.

Then Loeffler discovered the diphtheria bacillus,
and Koch the tubercle bacillus. Virchow and
others began doing autopsies systematically. It
was proved that most symptoms were the result
of demonstrable pathologic processes in various
organs. The doctor began to shift his attention
from results to causes, from therapeutics to diag-
nosis, from symptomatology to etiology.

Dr. Judd made this presentation at the graduation exer-
cises of the College of Medical Evangelists on June 11, 1961.
The school has since been renamed Loma Linda University.

This was the period in which I was trained — 40
years ago. It was called the era of therapeutic
nihilism. We concentrated our attention so much
on the disease that we almost forgot the patient.

Then, with better understanding of how dis-
eases were caused and communicated, a third em-
phasis naturally developed — preventive medicine.
The good doctor had to be an expert not only
with the stethoscope and the microscope, but with
the immunizing needle.

In more recent years, there has been an increas-
ing recognition of the effects of mind and emo-
tions on physiologic processes — and vice versa.
The doctors who only took care of the physiologic
processes were losing too many patients to those
who paid attention also to people’s emotions, and
gave them something to have faith in! Psychoso-
matic medicine belatedly came into its own.

Now we have entered a fifth stage in this
gradual metamorphosis. Now the doctor must
give more attention to public affairs, or he will
lose his professional freedom. During the de-
pression of the 1930’s, the hot war of the 1940’s
and the cold war of the 1950’s, our government
steadily expanded until it now reaches into every-
body’s life and everybody’s pocketbook almost
every hour of every day. How and under what
circumstances you are to practice your profes-
sions, what you will be able to earn, how much
of what you earn you will be permitted to keep,
and what you will be able to do with what you
retain, depend more than ever before on what
happens in Washington.

But decisions in Washington depend more than
ever before on what happens in Cuba, or Korea,
or Laos, or West Berlin.

What happens in those places depends on what
men decide in the Kremlin or in Peiping.

And what they decide in the Kremlin or Peiping
depends to a greater degree than we realize, I
think, upon what we say and do here in the United
States — or upon what they think we will do or
not do.

Nobody needs to be apologetic about discussing
government today. For unless we handle our af-
fairs in such ways as to maintain freedom and

263

264

Journal of Iowa Medical Society

May, 1962

peace in the world, there is no gain in America —
medical, social or otherwise — that will long be
worth much to anybody.

For conceivably, we could solve all our do-
mestic problems, we could have better medical
care more equitably distributed, we could meet
our housing needs, our education needs and our
old-age security needs, and get our labor-man-
agement problems settled, but unless we manage
our political and economic relations with the rest
of the world better than we have in the past, so
that we can win the cold war and end the pro-
longed and exhausting expenditures for defense,
none of the domestic gains can endure. If we don’t
spend more and more for arms, we invite insecu-
rity— and disaster. If we do spend more and more
for arms, and for everything else that has been
promised, too, we insure resumed inflation — and
disaster. Either way, disaster! That is why Mr.
Khrushchev smiles with confidence as he says,
“We will bury you!”

CIVIC ACTIVITY FOR THE BENEFIT OF PATIENTS

Your generation must play a more active role
in public affairs than medical people generally
have, for at least three reasons.

First, you must do it in order to ensure your
future as professional men and women, and to
safeguard the conditions under which you can use
to best advantage your knowledge of disease and
your skill in helping the sick.

Second, you must do it in order to work toward
betterment of environmental conditions that affect
your patients adversely. The man who comes to
you with arthritis or hypertension frequently has
something else wrong with him too. Perhaps he
has a boy in Laos or Korea, or in East Germany;
or his business is in difficulty; or inflation is eat-
ing up his life’s savings; or he is apprehensive
about atomic fallout and sputniks. He knows his
country is in deep trouble. He has legitimate
anxieties. If you are really going to help him deal
with his ulcers, or his insomnia, or his hyper-
thyroidism, you will have to pay more attention
to the impact on him of his world environment,
and get yourself into a position where you can in-
fluence that environment in the direction of con-
ditions more favorable to your patient’s well-be-
ing.

Third, you have to pay more attention to public
affairs in order to ensure your future as citizens.
Before any of us are doctors, or businessmen, or
lawyers, we are citizens of this Republic. All of
us are, or will be, taxpayers. Most of us are par-
ents. All of us are trustees of a great and noble
heritage of freedom — trustees of a political and
economic order which made it possible for even
those of you who came from humblest circum-
stances, as I did, to get the expensive education
which we could scarcely have dreamed of in most
countries of the world.

What we know as doctors about the practice of
the healing arts should and must influence our
thinking and our activities as citizens. But our
obligations as citizens must also influence our
thinking and conduct as doctors.

Generally we discuss what effect the govern-
ment’s actions may have upon us. It is equally es-
sential that we give thought to what effect we can
and must have upon government. For instance,
doctors almost to a man are opposed to socialized
medicine, and by socialized medicine I mean tax-
supported medical services provided and oper-
ated by the government. Most people, I fear, as-
sume that we oppose socialized medicine because
we think it would hurt the doctors. They think we
are a closed-shop union that wants to have com-
plete control of medical practice in order to pro-
mote our own selfish interests. We have failed to
show the public that our opposition to socialized
medicine is not because it would hurt us, but
because it would hurt the public.

As a matter of fact, socialized medicine wouldn’t
hurt most medical people financially. The superior
doctor can get ahead under any system. The poor
or even the average medical person probably
would be about as well off financially under so-
cialized medicine as under free competition. Fur-
thermore, he wouldn’t have to worry. He could
get a fairly well-paid, government-supported job
right after graduation — or, in the case of doctors,
after internship — and continue in that job for the
rest of his life.

Those who are more active in public affairs
than we are have taught the public to believe that
socialized medicine would give more and better
medical care for less cost. Doctors know it would
give less and poorer medical care at greater cost.

So, it is not because we are doctors that we op-
pose socialized medicine; it is because of what we
know as doctors about the practice of medicine.
But it is not enough for us to be right. We must
tell and sell our reasons to the public far better
than we have told them in the past. We can’t do
that by just talking to each other at medical meet-
ings. We have to reach the public and the poli-
ticians, not to put something over on them, but
to help them understand the situation so that no
one else can put something over on them.

COMMUNISM RESEMBLES CANCER

But doctors must play an even larger role in
public affairs. For example, who else can so well
understand, and who else can contribute so much
to helping other citizens understand the malig-
nant nature of the communist process which, in
the last 40 years, has spread its blight over one-
third of the world and which threatens the re-
mainder, including our own free America? If we
fail here, we fail everywhere.

For there is on this planet a conspiracy dedi-
cated to our destruction. The heritage of freedom

Vol. LII, No. 5

Journal of Iowa Medical Society

265

which enabled you to get where you are today,
and will permit you to decide tomorrow where,
how and with whom you are to practice, and what
organizations you are to join, ranging from medi-
cal societies to political parties — that heritage is
under cold, determined and increasingly success-
ful attack on every front.

The thing that makes a cancer bad is not its
size or its location; it is the lawless way in which
it grows. In practically all respects, the com-
munist movement behaves like other malignancies.
It has rejected the normal laws of growth, and
expands by lawlessly encroaching on tissues that
don’t belong to it. Sometimes it is by direct in-
vasion of an adjacent organ — or an adjoining
country like Finland, Korea, Hungary, Tibet or
Laos. Or it extends more stealthily by metastasis
into other organs, transplants of lawless cells,
lodging and working within other countries to
disrupt their economy, subvert their thinking,
weaken their institutions, in preparation for take-
over.

To deal successfully with the present malignant
threat to our survival, how urgently our country
needs the kind of mind which your medical col-
lege has given you!

First, it is the autopsy type of mind. You have
been trained to study the mistakes of the past and
admit them openly, in order to learn from them.
The doctor does autopsies not to cover up, but to
correct. In government, the prevailing rule is not
to correct, but to cover up. Each of the seven
conferences to which we have gone since World
War I, without careful and thorough agreement on
essentials in advance, has led to losses for freedom.
Yet how many people in public affairs today,
without your kind of mind, are urging our govern-
ment to try once more the same pattern that has
always failed.

We also need in public affairs more men with
the biopsy type of mind. When you look through
a microscope and see some abnormal cells that
have broken through the basement membrane in
violation of normal laws of growth, you don’t say,
“Well, it’s cancer all right, but it’s in a remote
organ. Let’s wait and see if it spreads.” You know
it will spread unless you find ways to stop it at
once and where it is. But during the last two
decades how many among our people have said,
“Isn’t it too bad what Hitler is doing to the Jews?”
“. . . what the Japanese are doing to the Chinese?”
or “. . . what the communists are doing to the
Hungarians?” But then they have said “Those
places are a long way off. Let’s see if we can’t
persuade the lawless elements to confine their
efforts to the areas presently involved, and not
spread them to us.”

Could Hitler be malignant to the Jews but be
benign toward us? Can communism be malignant
to others — Tibetans, Laotians, Cubans — but be
benign toward us?

The doctor knows that in dealing with a malig-
nant process there can be no end to the struggle
until one or the other prevails. That does not mean
that we must drop bombs on it. It does mean that
as a minimum we have to isolate it by cutting off
its sources of supply and its means of transmitting
its lawless cells to other areas. It means we must
prevent its winning new victories, such as ex-
panded trade or acceptance into respectable so-
ciety.

While fighting the malignant process, the doc-
tor knows that he must also build up the strength
and health of the rest of the organism — the coun-
tries and peoples that are still free.

We can’t win just by outwaiting the enemy; we
must outwit and outwork him!

We have been taught that almost the only un-
forgivable mistake for a physician is to under-
estimate the possible seriousness of a patient’s ill-
ness. If we overestimate it, we are guilty of noth-
ing but a little undue caution, but if we under-
estimate it, the patient may shortly be dead. The
mistake is unforgivable because it is irretrievable.

Likewise, in the world struggle between lawless
and law-abiding forces, it would be an unforgiv-
able mistake to fail to understand the malignant
character of the communist new growth — or to
underestimate its strength, its determination, the
dangerous inroads which it has already made into
the organs of our nation and into the thinking of
our people, without their realizing it. We must
not make that mistake ourselves — and it is our
duty not to let our fellow citizens make it.

OUR FUNDAMENTAL BELIEFS ARE CHALLENGED

For our patterns of thought and life are being
challenged in the most fundamental area of all—
our basic assumptions as to the nature of man.
Some years ago I heard the eminent Lebanese
philosopher Dr. Charles Malik, then president of
the United Nations General Assembly, say that
when the Conference on Human Rights convened
in Paris after World War II, the delegates spent
several months trying, in vain, to agree on what
man is. For how could they declare what the
rights are to which a human being is by nature
entitled until they decided what a human being
is?

Our society was founded by men who wrote as
their concept of the nature of man, “We hold
these truths to be self-evident, that all men are
created. . . .” They believed that there is a Creator;
that man is His child and therefore a paid of the
Creator. That is, man has in him qualities and
capabilities different from those possessed by any
animal; he has something of the divine in him.
He has the capacity to make moral judgments and
independent decisions based on those judgments.

The philosophy and faith of the communists re-
jects all this. They deny that there is a Creator;
that there are such things as moral laws, such

266

Journal of Iowa Medical Society

May, 1962

things as right and wrong, truth and falsehood,
good and evil; or that man is, by nature, a moral
being. They insist that he is merely the smartest
of the animals, the animal with the largest brain
— no more.

They believe, therefore, that just as the Rus-
sian physiologist Pavlov demonstrated that young
dogs can, by separation from older dogs and by
consistent control of their environmental stimuli,
be conditioned to make predictable, unvarying,
automatic responses, so with young human beings.
They believe that you and I think that we have
consciences and the capacity to make moral judg-
ments and independent decisions, only because
we have been taught that we have such capabili-
ties.

Thus, it is their mission to “liberate” us from
what they believe to be our errors. To do that,
they must first conquer the whole world, so that
they can then abolish the institution of private
property. It is private ownership of property, they
believe, that gives man the notion that he is a
distinct individual with “unalienable rights” and
importance as a person. They must, therefore, re-
move the child from his parents’ control or guid-
ance— as is done in Red China — before the par-
ents can communicate to him the “false” ideas
regarding man’s nature which the parents in their
childhood received, in turn, from their parents.
The state will then, by rigidly controlling the
child’s environment and what goes into his mind,
condition the child to seek nothing for himself, to
be cooperative, and to desire only to serve the
masses. Because no one will then try to take any-
thing from anyone else, there will be no more
clashes. Policemen will not be needed. The state
will wither away, and the perfect society — with
“peace and friendship” — will be established every-
where.

Some in the free world fiercely object that they
can’t go against human nature. The communists
reply that there is no such thing as human nature
— that human nature is what you make it. Capital-
ism, they say, makes it selfish, but communism
will make it selfless. Therefore, capitalism in-
evitably leads to clashes and war; communism, and
only communism, they insist, can lead to peace.

You and I believe that man is more than a phys-
ical and physiologic organism. We believe he has
in him, as an inherent part of his nature, some-
thing intangible called spirit or soul — something
divine. We believe, as doctors, that it has very
great influence on the state of his health, and on
the success of our efforts to cure his diseases and
relieve his sufferings.

We believe that to be good medical practitioners,
we must treat every patient, not just as a physical
mechanism with heart, lungs and liver needing to
be put back in order periodically, like carburetors
and spark plugs. We must treat each individual

as a distinct person, a whole person — body, minrl
and spirit. And the unique, the most precious, the
most vital thing about the human being is the
human spirit.

This world conflict is not an old-fashioned
struggle for the control of land; it is for control
of MAN — the mind of man, the soul of man, the
whole of man. No one of us dares fail to play his
full role in this total conflict — as a medical per-
son, as a citizen, as a human being.

Never did Americans face such a fundamental
challenge to the ultimate values of life. Never did
we have to think so deeply and work so hard as
we shall have to in the years just ahead if we are
to live in dignity and usefulness — or even to live
at all.

WHAT OTHER NATIONS WANT IS NOT
WHAT THEY NEED

I have said that we must not underestimate the
deadly character of the communist disease. It is
equally essential that we not underestimate the
strength of our own philosophy and faith — the
basic soundness of the American system and its
attraction and appeal to the oppressed millions of
the earth.

What the world generally wants most from the
United States is our wealth, our goods, our tools.
But those are not what it needs most, for those are
all results. What the world needs most from us is
the secret that produced those results.

The secret of our wealth is an economic system
which provides opportunity and incentive for men
to create, to produce, to expand, in order to im-
prove their condition.

That economic system came from a political
philosophy — the right of the individual. And from
what did that political philosophy come? It came
from a religious faith that put first the dignity and
worth of every human being as a child of God.

We shall not succeed in preserving the material
results unless we revitalize and strengthen the
spiritual roots from which they came. In short,
Christians will have to demonstrate as strong and
deep a faith in their fundamental tenets as the
communists have in theirs, and they will have to
work as hard and as skillfully to spread the truth
as the communists work to spread their falsehoods.

We must work both as individuals and as mem-
bers of the groups that we join and support be-
cause they are dedicated to the causes in which
we believe — religious groups, civic groups, po-
litical groups.

THE ANSWER: ENTER POLITICS!

So often one finds medical people unwilling — too
preoccupied — to work in political organizations.
Yet if you are to expend your influence in pub-
lic affairs, you must participate in politics, for it
is politics that determines government — the gov-

Vol. LII, No. 5

Journal of Iowa Medical Society

267

ernment which today determines the conditions
of your lives.

Therefore, join the political party that you think
is nearest right on the most important issues. You
won’t agree with it on everything, any more than
you agree on every issue with your classmates,
or with your medical society, or even with your
wife. But you don’t pull out of those associations
whenever you disagree. Rather, you stay in and
try to move your associates in the direction you
believe is right.

Just so, associate yourself with the party hav-
ing principles and programs with which you find
yourself in closest agreement, and work in and
through it to help select and then to help elect
good men and women to public office at every level
of government.

In addition, more medical people have to be
willing to be candidates for public office. That’s
tough, I can testify. But both patriotism and good
sense require that all of our citizens, no matter
how specialized their training, be willing to sacri-
fice their careers to go into public service in peace-
time, just as their sons are called upon to sacri-
fice their careers to go into the armed services in
wartime.

Only as you do these things — and not just dis-
cuss them — will there be hope. The most wonder-
ful thing about our country — the thing which we
must preserve at all costs — is the privilege we
have of changing the things we don’t like. Thank
God our system is such that whenever conditions
are bad, or don’t meet our standards, we can cor-
rect them — -if we will work in public affairs.

The way to begin is with ideas and principles,
to get persons and parties committed to them,
translate them into programs, and put them into
practice.

CONCLUSION

Please don’t think I am trying to lecture you
today, or imagine I have all the answers. Rather,
I am appealing to you for help. This world patient
is too sick to be cured without the intelligent and
dedicated effort of all of us. It particularly needs
the leadership of men and women who have the
qualities of mind and heart of the good physician,
nurse or therapist.

The tests ahead will be harder than those you
have just completed. But who is so well equipped
to mold the attitudes and actions of our people as
you who today leave the classrooms and clinics
of the College of Medical Evangelists to take up
your roles throughout our land and the world as
physicians, dentists, nurses, technicians and thera-
pists, and as citizens and trustees — strong, well
trained, confident, competent!

I congratulate you, your families, the communi-
ties into which you will go — and our country.

Quackery Booklet Ready
for Distribution

The entire medical profession is familiar with
the AMA’s continuing war to stamp out quackery.
The claims of pseudo-physicians and their worth-
less services, nostrums, gadgets and “therapeutic
programs” cost the American public over a billion
dollars yearly, plus an incalculable amount of
needless pain and suffering.

Last October, to coordinate and review anti-
quackery efforts, the AM A and the U. S. Food
and Drug Administration sponsored a joint Con-
gress on Quackery in Washington, D. C. The re-
sultant publicity and public response was over-
whelming and showed that quackery can be licked
when an aroused and aware citizenry confronts it.

Public education is the key weapon for use in
putting the quacks out of business. A new 15-page
booklet, containing cartoon illustrations in color
and entitled “Beware of ‘Health’ Quacks,” is one
of the many after-effects of the Congress. It does
an excellent job of exposing the medical pitchmen.
Its price is 5 cents per copy, and it is hoped that
physicians will order supplies of them for use in
their local anti-quackery campaigns.

Orders should be placed with the AMA Depart-
ment of Investigation, 535 North Dearborn Street,
Chicago 10.

Symposium on TB and Other
Pulmonary Diseases for GP’s

The eleventh annual Symposium for General
Practitioners on Tuberculosis and Other Pulmo-
nary Diseases will be held at Saranac Lake, New
York, July 9 through 13, under the sponsorship
of the American Thoracic Society (formerly the
American Trudeau Society), the New York State
Academy of General Practice, and the College of
General Practice of Canada.

A faculty of 33 outstanding authorities on tuber-
culosis, pulmonary neoplasms, bronchitis, emphy-
sema, and non-tuberculous pneumonias is being
assembled for this course. The recreational facili-
ties of the Saranac Lake area make it an ideal
place for physicians to bring their families for a
vacation.

The registration fee is $75, and a deposit of $10
should accompany the application. Information on
housing will be sent to physicians on receipt of
their applications. AAGP allows 27 hours of Cat-
egory I credit for the course.

Help your central office to maintain an
accurate mailing list. Send your change of
address promptly to the Journal, 529-36th
Street, Des Moines 12, Iowa.

Organ and Tissue Transplants at AM A Chicago Meeting

Progress of medical science in replacing defec-
tive organs and tissues with healthy “spare parts”
taken from donors will be reviewed and evaluated
at the American Medical Association’s 111th An-
nual Meeting in Chicago, June 24-28.

This program, which will contribute scientific
understanding to the underlying problems of tis-
sue transplantation, will be covered in a half-day
session by five physicians who have pioneered in
this field of experimental surgery and research in
biochemistry and immunology. The doctors are:
David M. Hume, of the Medical College of Vir-
ginia, Richmond; Ernst J. Eichwald, director of
the Laboratory for Experimental Medicine, Mon-
tana Deaconess Hospital, Great Falls; Joseph E.
Murray, Boston; Donald A. Roth, Veterans Admin-
istration Medical Center, Wood, Wis.; and Wil-
liam F. Enneking, chief of orthopedic surgery at
the J. Hillis Miller Health Center, University of
Florida at Gainesville.

The organ transplantation program, sponsored
by the A.M.A. Section on Orthopedic Surgery, will
be held on Wednesday afternoon, June 27, at Mc-
Cormick Place. In announcing the program, Dr.
John C. Wilson, Jr., of Los Angeles, secretary of
the A.M.A. Orthopedic Section of the Scientific
Assembly, said, “The advisability and feasibility
of organ transplantation is presently an exciting
frontier in medical science, and the committee
is delighted to have these five pioneering physi-
cians share their knowledge with all members of
the medical profession.” Dr. Wilson said that much
of the afternoon program would deal with the kid-
ney, an organ eminently suited for transplantation.
The elective sui'gical removal of one kidney in-
volves a definite although minimal risk, and the
surgical connection of the blood vessels of the
donated kidney to the vessels of the recipient is
generally not prohibitively difficult.

Dr. Murray and his colleagues from Peter Bent
Brigham Hospital have so far performed 16 kidney
transplants between identical twins, 15 of which
were initially successful. One patient died of a
technical failure. Two subsequently died within
a year after developing the same disease in the
transplant, leaving 13 patients now living and well
on transplanted kidneys from their identical twins.
All of the donors are living and well except for
one who was killed accidentally at work three
years after donating his kidney to his twin. His
recipient is still alive and well.

Although kidney transplantation between iden-
tical twins has proved fairly successful in many
medical centers, the surgical achievement is not
the complete answer to kidney problems. To pre-
vent a transplanted kidney from dying in a patient
other than a twin, scientists approached the im-
munologic problem in several ways, one of which

involves total body irradiation. Since it is anti-
bodies that destroy transplanted kidneys, they rea-
soned, why not try to prevent their formation with-
in the body. By administering massive, near-lethal
doses of radiation they found that it temporarily
suppresses the body’s means of producing anti-
bodies. In short, the radiation weakens the body’s
ability to defend against foreign tissue.

By applying this technique, a few kidney trans-
plants have been successful with patients in ap-
parent good health. At least three patients in the
world, two in France and one in a series at Peter
Bent Brigham, are now living with homotrans-
planted kidneys. “These successes highlighted in
a sea of failures could be the result of chance
genetic similarity,” Dr. Murray said in discussing
the A.M.A. program. “They indicate a need for
broad study of human genetics in the field of trans-
plantation.”

Another program participant, Dr. Eichwald,
chairman of the Transplantation Committee of the
National Academy of Sciences, said he would dis-
cuss many other problems associated with trans-
plantation of organs, generally. “The problem of
procurement and storage of spare parts looms
large,” he said, “and unless significant changes
occur in our handling of the deceased, the supply
will always remain a mere trickle.” Dr. Eichwald
said that with medical science overcrowding more
and more obstacles associated with organ trans-
plantation, the need for transplanted organs will
remain high.

Dr. Enneking, another program participant, who
is presently serving as president of the Ortho-
paedic Research Society, will discuss various pre-
pared material, such as lypholized bone, curetted
bone, beef bone and synthetic materials that are
clinically employed as bone grafts. In discussing
his lecture, Dr. Enneking said he would stress the
fact that bone, unlike other tissue following trans-
plantation, does not permanently remain as a
transplant. The bone, he pointed out, is gradually
incorporated into the skeleton and then, in the
normal physiological process, is replaced by new
bone for the remainder of the patient’s life.

Dr. Roth, who is chief of the Metabolic and
Rheumatic Disease Section of the Veterans Ad-
ministration Center at Wood, Wis., will review
the surgical cases of two young men who suc-
cessfully underwent kidney transplants from twin
brothers. Both men are now married and employed
in Milwaukee. The first patient, James Ray, now
24, underwent surgery for a kidney transplant in
June, 1958, and the other patient, John Riteris,
now 21, underwent similar surgery in January,
1959. Dr. Roth said that both patients will be in
attendance at the A.M.A. transplantation session,
and will be introduced to the physician audience.

268

Bell's Palsy

MAURICE W. VAN ALLEN, M.D.

Iowa City

Bell’s palsy is one of the oldest of the neurologic
syndromes, but it is sufficiently common to warrant
periodic reconsideration. Proper diagnosis is im-
portant, the sequelae are interesting, and the treat-
ment— previously limited to physical therapy — is
now the object of renewed attention. Paralysis of
the facial nerve with accompanying loss of facial
movement and expression has borne the eponym
“Bell’s palsy” since early in the nineteenth cen-
tury, when Sir Charles Bell demonstrated that the
VII cranial nerve subserved motor function to the
face. He later desci'ibed cases of paralysis of the
facial nerve.

In recent years, the term has been regarded as
properly applied only to the acute paralyses of the
facial nerve without evidence of trauma or of
other disease. The facial nerve is more frequently
the victim of so-called mononeuritis or isolated
paralysis than is any other of the vulnerable
nerves, e.g., the ulnar, median, peroneal or lateral
femoral cutaneous. It is especially susceptible to
injury from direct trauma, basal skull fracture,
mastoiditis, surgical procedures to the ear and
parotid, and various neoplasms. However, this dis-
cussion will be limited to the spontaneously-oc-
curring instances of isolated paralysis of the nerve.

ANATOMY

The motor component of the facial nerve arises
in a complex of nuclear masses in the caudal part

Dr. Van Allen is an associate professor of neurology at
the State University of Iowa, College of Medicine. This work
was made possible by the Harriett Ames Charitable Trust
Grant in Cerebral Palsy Research awarded by the United
Cerebral Palsy Foundation and by the facilities of the
Neurosensory Center. The Neurosensory Center is supported
by program -project grant No. B-3354 of the National Insti-
tute of Neurological Diseases and Blindness of the United
States Public Health Service. Dr. Van Allen presented this
paper on December 11, 1961, to the medical staff of the
Veterans Administration Hospital in Des Moines, Iowa.

of the pons (Figure 1). It follows a peculiar course,
looping about the nucleus of the abducens nerve
before emerging from the brain stem to enter the
internal acoustic meatus with the stato-acoustic
nerve (the VIII cranial) and the intermediate
nerve. In ordinary usage, the VII cranial nerve
and its parasympathetic and viscero-sensory com-
ponent, the intermediate nerve, are considered to-
gether as the facial nerve. This nerve has a longer
course through a bony canal than any other — ap-
proximately 3 cm.1 The route is circuitous, and
close to mastoid cells and tympanum. Three im-
portant branches of the nerve are given off in its
course through bone (Figure 2). The greater su-
perficial petrosal nerve carries nerve impulses to

Figure I. The relationship of VII nerve to the abducens
(VI nerve). An intramedullary lesion of the VII nerve or its
nucleus will usually involve the abducens as well. Simila rly,
a lesion involving the nucleus or intramedullary fibers of the
VII nerve will usually result in partial paralysis on the oppo-
site side of the body as a result of damage to the descend-
ing corticospinal tract.

269

270

Journal of Iowa Medical Society

May, 1962

the tear glands and nasal mucosa. The chorda
tympani nerve in most subjects conducts taste
sensation from the anterior portion of the tongue,
and carries parasympathetic fibers to salivary
glands. Both of these are branches of the inter-
mediate portion of the facial nerve. A small motor
branch innervates the stapedius muscle. The facial
nerve, descending vertically through bone for a
short distance, leaves the skull just anterior to the
mastoid process through the stylomastoid foramen.
In this region, the nerve is relatively snug in its
bony canal. On leaving the canal, the nerve quickly
branches — spreads through the parotid gland and
distributes to the facial muscles including the
platysma.

The blood supply of the nerve is important to
the current concepts of the pathogenesis of Bell’s
palsy. The nerve is supplied by branches of the
auditory and middle meningeal arteries from
above, and by the stylomastoid artery from below.

SYMPTOMATOLOGY

Young and middle-aged adults are more com-
monly afflicted, and no difference in sex incidence
has been noted. Although Bell’s palsy is seen as
frequently in the summer as in the winter, a his-
tory of chilling of the face is often given. Hence,
the presumptive name “paralysis e frigore.”

The patient may not note his paralysis until
food or fluid dribbles from one side of his mouth,
or until a change in his speech is noted. More often,
he is first aware of a sensory disturbance in his im-
mobile face. This, he perceives as a “numbness” or
“stiffness.” Pain of varying severity in the mastoid
region is not uncommon. The loss of function may
be complete and precipitous in onset, or incom-
plete at first and progressive over a period of
several hours or days. In a substantial number of
patients, loss of function is never complete. About
50 per cent of the patients will volunteer or attest
to a disturbance of taste, and some loss of taste
may be demonstrated by examination. Vertigo and
disturbed hearing may result from the same
ischemic changes that cause paralysis of the facial
nerve.

EXAMINATION

Reduced or absent activity of facial muscles will
be recognized easily during the expressional
changes accompanying ordinary discourse, and with
few exceptions the entire side of the face will be
variously involved. Regional testing of the facial
musculature can then be carried out, and this is
largely done by inspection. The patient is asked to
frown and then to elevate his brows. If he can’t do
this easily, he can be told to look upward, and his
brows will elevate as he does so. An asymmetry
will be evident. Then he is asked to close his lids
tight. In case of doubt about weakness on one side,
it is helpful to have him attempt to close his lids
against resistance. Observation of involuntary
blinking in cases of partial paralysis is most use-

Figure 2. A sketch to illustrate the course of the facial
nerve in the temporal bone. The branches are indicated.

ful. The incompleteness of lid closure on the in-
volved side can easily be appreciated. The central
musculature can be tested by asking the patient
to “wrinkle” his nose as if he were sensing a bad
odor. Attempts to blow out the cheeks will show
both the flaccidity of a weak buccinator muscle and
the escape of air past the orbicularis oris which
cannot approximate the lips tightly enough on the
paretic side. The platysma is tested by asking the
patient to pull down the corners of his mouth.
Often, this movement pattern must be demon-
strated for him.

Since prognosis based on clinical findings de-
pends so heavily upon the degree of completeness
of the paralysis, a few minutes spent in very close
observation of the patient’s face is in order. Care-
ful inspection may reveal slight flickers of move-
ment about the forehead, lower lid or mouth,
whereas at first glance the paralysis has appeared
complete. One must be very careful to distinguish
between movement due to residual activity and
that caused by a pulling of the skin across the mid-
line. Particularly misleading are the movements
of the upper lid, which will drop in blinking and
will automatically follow the downward-moving
eye even when the orbicularis oculi is completely
paralyzed. The mentalis muscle covers the central
portion of the chin. It is likely that some degree of
innervation crosses the midline here, and thus this
region should be evaluated skeptically.

Reduced tearing is not easily detected, but taste
may be tested by having the patient put a few
crystals of salt, sugar or quinine on his tongue
and then make a subjective comparison of the
abilities of the two sides of his tongue in tasting

Vol. LII, No. 5

Journal of Iowa Medical Society

271

them. The patient should not close his mouth dur-
ing this test, and he should wash out his mouth
with water between the tests of different sub-
stances.

DIAGNOSIS

At this point, the physician has two basic obliga-
tions to the patient. The first is to make an ana-
tomic diagnosis, and the second is to make an etio-
logic diagnosis. These two endeavors are not en-
tirely separable, but may be so considered in the
early examination. Facial paralysis of central ori-
gin must be distinguished from that due to in-
volvement of the peripheral nerve. This is a classic
differential diagnosis in neurology (Figure 3). In
paralysis due to disorder of the central nervous
system (commonly cerebral infarction), the paral-
ysis is usually not so profound, and some move-
ment of the facial muscles is usually seen. Most
important is the normal or near-normal movement
of the bilaterally innervated forehead. Seldom does
partial peripheral paralysis mimic this sparing
of the forehead, and seldom does central paralysis
prevent the patient from closing the lids. Occasion-
ally, it is helpful to elicit the facial reflexes, since
preservation or exaggeration of the stretch reflex
in the presence of immobility is the hallmark of
central or upper motor neuron paralysis. Tapping
the forehead at the bridge of the nose results nor-

mally in a brief contraction of the lids — best seen
in the lower lids. This contraction will be dimin-
ished or absent on the side of peripheral nerve
paralysis, and present or exaggerated on the side
of central face paresis.

Just as important to anatomic diagnosis is the
elicitation of symptoms or signs pointing to in-
volvement of functions other than those of the
facial nerve. Weakness or awkwardness of the ex-
tremities, diplopia, difficulty in swallowing and
trouble in finding words are not parts of Bell’s
palsy. Essential to the diagnosis of Bell’s palsy,
then, is the absence of signs not referable to the
nerve or its immediate environs.

Those pathologic changes which cause paralysis
of the nerve in its course in the medulla are un-
common and almost always associated with in-
volvement of the pyramidal tract (hemiparesis)
and paralysis of the external rectus muscle on the
same side (Millard-Gubler and Foville syndromes,
see Figure 1).

When one is satisfied that only the peripheral
nerve is involved, attention should be directed to
signs of disease or injury in the mastoid and in
the parotid region. Basal skull fracture and local
trauma should be obvious. Infections of the mas-
toid causing facial paralysis are usually of long
standing, and signs of inflammation are evident.

Herpetic eruptions in and about the ear may ap-

Figure 3. Comparing the features of peripheral and central facial paralysis: (a) Complete peripheral facial paralysis, right.
All of the facial musculature on this side is inactive, including the frontalis and platysma. (b) Central facial paralysis, right.
The musculature below the eye is relatively inactive. Contraction of the frontalis is well preserved.

272

Journal of Iowa Medical Society

May, 1962

pear and may be associated with considerable pain
in this region. Disturbance in hearing, vertigo and
other cranial-nerve paralyses may be associated
with the herpes. This is the Ramsay-Hunt syn-
drome or “geniculate herpes” — a viral infection
often associated with fever and malaise. It accounts
for a small percentage of cases of facial paralysis.

Facial paralysis may be a very early sign in in-
fectious polyneuritis (Guillain-Barre syndrome),
but if so, it will soon be followed by numbness and
weakness of the extremities. The facial weakness
often is bilateral in this condition. Facial paralysis
is also seen in poliomyelitis, but seldom without
other findings. Paralysis of the facial nerve is un-
commonly due to hypertensive hemorrhages or
leukemia. The facial paralysis due to an intra-
medullary lesion of multiple sclerosis — -an uncom-
mon manifestation of this disorder — is probably
indistinguishable from Bell’s palsy.

Usually, it is readily apparent that only the
facial nerve is involved, and usually local patho-
logic processes complicated by a rapidly develop-
ing facial paralysis are easy to detect. It never-
theless is often advisable to obtain roentgenograms
of the mastoids. Having decided that one is deal-
ing with Bell’s palsy, he has two major obligations
remaining — prognosis and treatment. But before
going on with these matters, it seems appropriate
here to discuss what is known of the pathologic
changes in this disorder.

PATHOLOGY

Most of our knowledge of the pathologic changes
in Bell’s palsy has come from observations made
at the time of therapeutic surgical decompression
of the nerve. The current theory of pathogenesis has
likewise been reinforced by these observations.
Kettel,2 in his recent monograph, describes swell-
ing of the nerve, exudation, and evident constric-
tion of the nerve by its investing sheath. There is
little evidence of inflammation, but necrosis of
surrounding mastoid bone can be seen in the
severe cases. The nerve has shown edema, myelin
breakdown and small hemorrhages.

The pathogenesis is considered by most to rest
on primary vascular changes — i.e., spasm, with
ischemia, anoxia and swelling. The bony canal
limits expansion, the swelling further reduces
blood flow, and thus the process may go on to
necrosis. The breakdown of surrounding bone is
attributed to ischemia from the same source. When
necrosis of the nerve is complete, recovery must
come through regeneration.

It is this theory of vascular spasm and its con-
comitants that forms the basis for currently-rec-
ommended therapy, both medical and surgical.

PROGNOSIS

Peripheral nerves may be made non-conductive
by pressure or ischemia, and yet not degenerate or
allow their muscles to do so. A physiologic block

Figure 4. Contracture on the right following recovery from
paralysis of this facial nerve. A constant state of contraction
involving a lew motor units results in an accentuated naso-
labial fold. This sequela is in many cases fortunate, in that
facial expression at rest is preserved, and most post-paralytic
sagging of the face is avoided. It is associated with other
evidences of imperfect innervation (see Figure 5). It is also
seen in those patients who develop hemifacial spasm (Fig-
ure 6) .

is then said to exist. No nerve impulses are trans-
mitted, and the innervated muscle is paralyzed. In
this state of affairs, rather rapid and complete
return of function is possible if noxious influences
are withdrawn. Such a physiologic block seems to
exist in a sizeable percentage of cases of Bell’s
palsy. Some fibers of the nerve, of course, remain
functional in the partial paralyses. However, the
nerve may be completely disrupted, and return of
function must await regeneration, which requires
approximately two months for the earlier manifes-
tations. Doubtless in many cases of clinically com-
plete paralysis, a varying combination of block and
degeneration exists. Such a complicated state of
affairs would easily explain the widely varying
clinical course.

I shall rely considerably on the reports of Tav-
erner3 for the following information on prognosis.
The greater the degree of preserved function, the
better the prognosis for recovery. In such cases of
partial involvement, recovery may begin in 2-21
days, and is likely to be complete in 6-8 weeks.
When paralysis appears complete to observation,

Vol. LII, No. 5

Journal of Iowa Medical Society

273

prognosis is more difficult. If pain around the mas-
toid is severe and paralysis is complete, there is
an excellent chance that complete denervation will
take place — that recovery will be delayed and in-
complete, with varying sequelae to be discussed
later.

The use of electromyography, a study involving
the detection and analysis of the electric potentials
of contracting muscle, although not generally avail-
able, is of considerable value in prognosis. When
this method shows evidence of fibrillation poten-
tials (small, brief electric changes typical of de-
nervated muscle) then a destructive lesion of the
nerve may be inferred, and recovery will take
several months and will not be perfect. When such
abnormal electrical activity does not appear (after
a minimum of 10-14 days) , there may well be a
physiologic block, and prognosis is much better
for an early and complete recovery. Under these
circumstances, the peripheral nerve remains stim-
ulable by faradic and square wave electric currents
applied over its trunk. Obviously, repeated studies
may be necessary. Electromyography must be con-
sidered in the same light as other laboratory aids,
but it has definite value in these circumstances. It
is also of value in detecting the earliest signs of
contracting muscle before they are visible to the
physician.

SEQUELAE

In those cases where paralysis is partial and/or
where function returns soon, complete recovery is
the rule.

When return of function is more protracted be-
cause of partial or complete denervation, recovery
is never complete, although it is often satisfactory
for cosmetic purposes, for protection of the eye
and for lip movements in speech. The sequelae are
as follows:

1. Imperfect function — i.e., loss of strength and
range of movement

2. Contractures or persistent mild contraction
usually seen as deepening of the nasolabial fold

3. Abnormal associated movements

4. Excessive tearing or “crocodile tears” where
tearing is associated with eating

5. Hemifacial spasm — a condition of irregular,
uncontrollable spasmodic twitching of the face

6. Persistent disturbance in taste (most uncom-
mon).

The first of these is self-explanatory and of vary-
ing degree. Almost never does the nerve fail to
show some evidence of regeneration. Contracture
is seldom a problem to the patient, and indeed it
helps to preserve the facial contour in the more
severe cases (Figure 4) .

Figure 5. Abnormal associated movements following recovery from paralysis of the facial nerve on the right, (a) On
closing the eyes or blinking, the patient exhibits abnormal associated contraction of the musculature about the mouth and
chin, (b) The lips are puckered, and partial closure of the lids is seen on the same side.

These synkinetic contractions are presumed to be due to misdirection and sprouting of regenerating axons. The refinements
of expression are lost as fewer axons distribute widely in the facial musculature, resulting in mass movements.

274

Journal of Iowa Medical Society

May, 1962

Abnormal associated movements may be a nui-
sance cosmetically and also because of the twitch-
ing sensations produced. Efforts to purse the lips
or show the teeth may cause partial closure of the
lids (Figure 5b). Most notable are the movements
about the mouth or chin associated with blinking
(Figure 5a). These movements are of theoretical
interest, and are now presumed to be due to sprout-
ing and misdirection of the regenerating axons. A
nerve fiber originally directed to the musculature
of the lids sprouts, on regeneration, sending
branches to the orbicularis oris, mentalis and other
muscles. Hence, the patient literally blinks his
lips or other parts of his face. Occasionally these
“blinks” are of use to the physician. The first sign
of recovery may be a contraction about the mouth
or chin when the patient attempts to blink.

Hemifacial spasm, which is infrequent as a major
complication of Bell’s palsy, is probably in some
way related to these synkinesias. When severe,
the repeated irregularly-occurring facial spasms be-
come most distressing and disfiguring (Figure 6).
Frequently the contractions begin in the lids and
then spread to the rest of the face. Treatment by
decompression of the nerve or partial resection is
only occasionally successful.

The syndrome of “crocodile tears” is also related
to the abnormal synkinesias. Here it is presumed

that fibers of the intermediate portion of the nerve
normally innervating the salivary glands are re-
distributed to the tear glands. The patient is an-
noyed by a copious flow of tears when he should
be salivating over a tempting steak. This rather
uncommon syndrome can be treated by surgical
section of the greater superficial petrosal nerve.

Excessive flow of tears not related to eating is
also seen, and ordinary tearing is troublesome
during paralysis when the lower lid sags away
from the globe and the flow of tears is not directed
into the normal drainage channels.

TREATMENT

Older forms of treatment have included massage
of the face, and electrical stimulation aimed at
maintaining the muscle in a good trophic state
while passively awaiting reinnervation. Probably
neither of these is of much value, but both have
places in the management of a distressed patient.
Taping of the face to prevent sagging is a nuisance
and probably has no value. Protection of the cor-
nea and conjunctivae from exposure by instillation
of artificial tears, by the use of an eye shield or
even by lid closure may be necessary in severe
cases. The patient must be warned of the vulner-
ability of the eye during facial palsy.

Newer modes of therapy are based on the theory

Figure 6. Hemifacial spasm, an uncommon sequela of facial-nerve paralysis, is illustrated here, (a) The irregularly occur-
ring spasm usually begins in the orbicularis oculi. The peculiar expression taken from a photograph may have been due, in
part, to an effort to keep the lids open, (b) The spasm is fully developed, involving all of the musculature on the right. The
disfigurement is striking. The patient who served as a model for this sketch had a cataract on the left, and thus was blinded
during the attacks. The mechanism of this condition is not understood. Hemifacial spasm may occur without preceding Bell's
palsy.

Vol. LII, No. 5

Journal of Iowa Medical Society

275

of a vascular origin for the disorder. They are
aimed at early relief of presumed vascular spasm
and at relief of secondary edema of the nerve.

The administration of daily intramuscular and
oral nicotinic acid, in doses sufficient to cause
flushing and continued for a week, may have value
and is worth trying.4 The use of prednisone in daily
doses of 30-40 mg. for 4-6 days and then tapering
off, with the usual precautions, has been recom-
mended but has not proved beneficial.

Korkis5 has reported good results in reducing
the period of paralysis by early stellate ganglion
block with local anesthetic agents. This has not
been substantiated, and though I cannot comment
from experience, I favor a trial of this method
early in the course of the paralysis and a critical
appraisal of the results.

Surgical decompression of the nerve in its bony
canal is a procedure that is now possible for the
experienced otologist. Its advantages are the sub-
ject of argument, in view of the high rate of natural
recovery, but the possibility of reducing the se-
verity of sequelae should not be ignored. Even the
more enthusiastic do not now recommend surgery

until two months have passed without sign of
recovery. When one reflects on the high rate of
eventual recovery — complete or satisfactory in
more than 80 per cent of cases, and often begin-
ning early — it is easy to see how difficult it is to
evaluate any therapeutic methods.

I would recommend physical therapy, protec-
tion of the eye, the use of nicotinic acid, and con-
sideration of early stellate ganglion block.

ACKNOWLEDGEMENT

I wish to express my appreciation to Mr. Alan O.
Hage, who prepared the illustrations.

REFERENCES

1. Cawthorne, T., and Hayes, D. R.: Facial palsy. Brit. M. J.,
2:1197-1200, (Nov. 24) 1956.

2. Kettel, K.: Peripheral Facial Palsy: Pathology and Sur-
gery. Springfield, Illinois, Charles C Thomas, 1959.

3. Taverner, D.: Prognosis and treatment of spontaneous
facial palsy. Proc. Roy. Soc. Med., 52:1077-1080, (Dec.) 1959.

4. Kime, C. E.: Bell’s palsy: new syndrome associated with
treatment by nicotinic acid. A.M.A. Arch. Otolaryng., 68:28-
32, (July) 1958.

5. Korkis, F. B.: Treatment of recent Bell’s palsy on rational
etiological basis: results of cervical sympathetic block and
corticosteroid therapy. A.M.A. Arch. Otolaryng., 70:562-569,
(Nov.) 1959.

Dean of the S.U.I. College of Medicine Resigns

Dr. Norman B. Nelson, dean of the State Uni-
versity of Iowa College of Medicine and director
of University Hospitals since 1953, has submitted
his resignation, effective June 30. He will become
Director of Medical Institutions for Santa Clara
County, with his office to be located at San Jose,
California.

A native Californian, Dr. Nelson came to S.U.I.
from Beirut, Lebanon, where he had been serv-
ing as medical dean at the American University of
Beirut. Prior to his appointment there he had
served for five years as assistant dean of medi-
cine at the University of California at Los Angeles,
and before that he had been associated with the
Los Angeles Department of Health. He has done
considerable research in the study of epidemics,
particularly in the epidemiology of polio. Dr. Nel-
son, 49, earned his B.A. degree at California in
1934, his M.D. at Southern California in 1939, and
master’s and doctor’s degrees in the field of public
health at Harvard University in 1941 and 1942.

In announcing Dean Nelson’s resignation, S.U.I.
President Virgil M. Hancher commented, “The
resignation of Dean Nelson brings to an end nearly
a decade of able leadership in the University Col-
lege of Medicine. Because of his background and
experience, he brought to the College of Medicine
of this University an unusual understanding of the
relation between the basic and clinical sciences,
between teaching and research, between the work
of the general practitioner and the specialist, and
between the profession and the public. Dean Nel-

son and the University can take great pride in the
remarkable achievements of the College of Medi-
cine during his administration.”

The editors of the journal, speaking for them-
selves and for the members of the Society, join
the faculty at S.U.I. and his many other friends in
Iowa in wishing Dean Nelson and his family con-
tinued success and happiness.

The Biochemical and

Clinical Aspects of

Acetylsalicylic Acid

W. D. PAUL, M.D., and
J. I. ROUTH, Ph.D.

Iowa City

The naturally occurring salicylates found in bark,
leaves and fruit of many plants and trees have
been used as remedies by physicians and laymen
alike for over 20 centuries. Hippocrates, Celsus
and Pliny described their application prior to and
during the first century of the Christian era. Pastes,
infusions and juices of leaves and bark were em-
ployed in the removal of warts and in the treat-
ment of sciatica, ear ache, skin diseases and gout.
The value of natural salicylates in the treatment
of fevers was recognized by laymen, but the med-
ical profession was not generally informed of it
until the appearance of a publication by Reverend
Edward Stone, in 1763.92

The chemical structure and properties of the ac-
tive substance in willow bark were investigated
rather intensively between 1825 and 1840. The glu-
coside salicin, salicylaldehyde and salicylic acid
were prepared from natural sources. Gerland31
first synthesized salicylic acid in 1852 through the
action of nitrous acid on anthranilic acid. Kolbe,49
in 1860, used a different method for synthesis, and
by 1874 the synthetic compound became available
commercially by virtue of a procedure that he and
Lautemann50 developed.

Soon after synthetic salicylic acid became avail-
able, several clinical reports concerning its ther-
apeutic value appeared. Its antipyretic usefulness
was confirmed, and in addition, Strieker94 and
MacLagen52 reported, in 1876, that salicylates were
a specific remedy for rheumatic fever. Apparent-
ly, however, the natural salicylates had been used
in treating rheumatic diseases for many years be-
fore the appearance of the formal medical report.

In 1853, von Gerhardt had prepared acetylsalicyl-

Dr. Paul is a professor of physcial medicine and rehabilita-
tion, and Dr. Routh is a professor of biochemistry at the S.U.I.
College of Medicine. The studies reported here were sup-
ported in part by a grant from the Iowa Chapter of the
Arthritis and Rheumatism Foundation, and in part by a
grant from Bristol-Myers Company, of New York City.

ic acid through the action of acetylchloride on
sodium salicylate,30 but this compound was not
applied therapeutically until the end of the nine-
teenth century. Both Wohlgemut101 and Dreser20
introduced it into medical practice in 1899.

SALICyLATE CONCENTRATIONS IN BODY FLUIDS

Early methods for determining the concentra-
tions of salicylates in blood and urine required
large specimens, involved tedious procedures and
often lacked accuracy. Probably the oldest and
most commonly practiced method involved extrac-
tion with ether, as outlined by Feser and Fried-
berger in 1875. 23 From 20 to 100 ml. of blood or
100 ml. of urine was repeatedly extracted with sev-
eral portions of ether, and then the extracts were
evaporated, the residue was decolorized with char-
coal, and the resulting solution was treated with
ferric alum to develop a violet color. Then the
color was compared with that of standard salicyl-
ate solutions treated with ferric alum. Various in-
vestigators had trouble with emulsions in the
ether-extraction step and were unable to decolor-
ize the residues completely with charcoal. Mosso55
found, in 1889, that salicyluric acid, as well as sal-
icylic acid could be extracted from urine through
the use of a mixture of ether and ethyl acetate.
After the extract had been evaporated, the residue
was subjected to a complex series of steps, cul-
minating in a gravimetric analysis of the two com-
pounds. In 1912, Sauerland76 improved the meth-
od for urine by saturation with ammonium sulfate
and extraction by means of a mixture of petro-
leum, ether and chloroform. The extract was
shaken with water containing ferric alum until no
more violet color could be extracted. Then the
colored solution was placed in a cylinder and
visually compared with a similar solution pre-
pared from a standard salicylate solution. Later
authors found that the violet color faded and that
the method lacked quantitation.

In 1915 and 1917, Hanzlik and co-workers36- 98 im-
proved the method for determining the salicylate
concentration in urine by employing acid hydrol-
ysis followed by steam distillation and color-
imetric determination of the salicylate in the dis-
tillate after the addition of iron salts. They used

276

Vol. LII, No. 5

Journal of Iowa Medical Society

277

100 ml. of urine plus 20 ml. of syrupy phosphoric
acid, and distilled the mixture to near dryness.
They reported 90-95 per cent recovery of 5 to 10
mg. of salicylate added to 100 ml. of urine, and
of 2 to 5 mg. added to 10 to 20 ml. of blood. The
blood specimens were extracted with several por-
tions of ether. Then the extracts were evaporated,
the residue was dissolved in hot water, and ferric
alum was added to develop the color.

In 1936, Bradley6 developed a rapid method for
measuring salicylates in urine, gastric juice and
spinal fluid based on the carbon dioxide liberated
by brominating salicylic acid in the Van Slyke
volumetric gas-analysis apparatus. He observed
that five to six hours of steam distillation from
phosphoric acid, as employed by Hanzlik and co-
workers, did not remove all the salicylic acid from
urine. The main disadvantage of the Bradley
method was that it could not be applied to blood
specimens.

In the late nineteenth century and early twen-
tieth century, several investigators had reported
salicylates in the urine, blood, spinal fluid, syno-
vial fluid and ascitic fluid. The results had been
qualitative or roughly quantitative. Floeckinger27
had studied the hydrolysis of acetylsalicylic acid
in the gastrointestinal tract in 1899, and in 1902
Fillipi and Nesti25 had reported salicylates in
synovial fluid, ascitic fluid and urine after the
administration of 2 Gm. of the acetylated com-
pound. In 1917, Hanzlik and his co-workers had
reported quantitative levels of salicylate in blood
and synovial fluid.79 They had administered 5 to
14 Gm. of sodium salicylate to normal individuals
and found an average level of 20 mg./lOO ml. in
the blood and 18 mg./lOO ml. in the synovial fluid.
Samples of 10 to 30 ml. of blood and 7 to 20 ml.
of joint fluid had been used for the analysis.
Specimens of such magnitude are impractical for
routine analysis. In another series of experiments,
they had compared a group of non-rheumatics
who had received 9 to 19 Gm. of sodium salicylate
with a group of rheumatics who had received 5
to 17 Gm. The average blood level of the first
group had been 26.5 mg./lOO ml., versus 21 mg./lOO
ml. for the second. In all cases, specimens had
been drawn when the subjects showed signs of
salicylate toxicity, without regard to uniform time
intervals.

In 1922, Fiessinger and Debray had given 1 Gm.
of sodium salicylate to individuals, and had deter-
mined the concentrations of salicylate at various
intervals.24 Levels had been obtained at 10, 20 and
30 minutes, and at 1, IVi , 5, 12, and 18 hours — 4.5,
5.5, 5.5, 10, 6 and 1 mg./lOO ml., respectively.

RELATIONSHIPS BETWEEN DOSAGES AND ATTAINED
CONCENTRATIONS

The first major investigation of the relationship
between the dose and the blood level was carried
out on patients with rheumatic fever by Coburn,14
in 1943. In a group of ten patients, each of whom

had received 10 Gm. of sodium salicylate daily for
three days, the concentrations in the plasma on the
fourth day ranged between 29 and 52 mg./lOO ml.,
with a poor correlation between the dose and the
concentration. Coburn suggested a plasma level of
40 mg./lOO ml. as the minimum for effective ther-
apy in rheumatic fever.

During the following year, 1944, Brodie, Uden-
friend and Coburn7 described the salicylate meth-
od that has gained widespread acceptance. Their
method employed 1 or 2 ml. plasma samples, and
involved the extraction of salicylates with ethylene
chloride. The salicylates were then transferred
back into an aqueous solution containing ferric
nitrate for development of the violet color. P. K.
Smith and his co-workers85 adapted the method to
the determination of urinary salicyluric acid and
salicylates in 1946. They also applied the method
to the estimation of plasma salicylate levels in
normal subjects who had been given 2 Gm. of
either sodium salicylate or acetylsalicylic acid.
Blood specimens were drawn at intervals ranging
from % hour to 8 hours after the administration
of the salicylate. In both series, the maximum con-
centration was reached within 1 to 2 hours, and
as Coburn had reported, there were considerable
variations in levels from person to person. Ap-
proximate levels 1, 2, 4, 6 and 8 hours after inges-
tion were 12, 15, 14, 12 and 7 mg./lOO ml. for
sodium salicylate, and 6, 10, 11, 10 and 9 mg./lOO
ml. for acetylsalicylic acid.

SEMIMICRO DETERMINATION OF BLOOD
SALICYLATE LEVELS

In the past two decades, many investigators
have applied the Brodie method and its modifica-
tions to the determination of salicylate levels in
studies of absorption, excretion, protein binding,
effect of buffers and antacids, and other routine
therapeutic questions. Recently, there has been re-
newed interest in the relationship between the
dose and the salicylate levels at various time in-
tervals. In the course of our investigations, we
have had occasion to determine the salicylate
levels in all types of body fluids, whole blood,
plasma, serum and tissue samples. At times we
have been handicapped by low salicylate levels,
insufficient available volumes of samples and the
necessity for frequent sampling.

The majority of investigators have determined
salicylate levels 30 minutes to one hour after the
ingestion of salicylates. We have long felt that it
would be of interest to study the levels that occur
within the first few minutes after ingestion of the
drug. Such an experiment would involve large
numbers of patients, in order that venipunctures
might be obtained at staggered intervals. If more
frequent specimens could be taken from a par-
ticular patient, additional information could be ob-
tained concerning salicylate levels versus dosage
versus time.

To implement this study, we have developed a

278

Journal of Iowa Medical Society

May, 1962

semimicro method for determining salicylate levels
in blood.74 An 0.2 ml. specimen of blood, serum
or plasma is employed, and all extracting, shak-
ing and centrifuging is carried out in 12 ml. glass-
stoppered centrifuge tubes. The method is capable
of determining levels of 0 to 50 ug./ml., as well
as 10 to 50 mg./lOO ml., and can be used on finger-
tip blood specimens. It is characterized by low
plasma or whole blood blanks, and is well suited
for the determination of the low levels of salicyl-
ate expected in the first few minutes after salicyl-
ate ingestions. Other methods, especially the “sin-
gle solution” type,16’ 46- 99 are characterized by
high erratic blanks and thus are incapable of ac-
curately estimating low levels of salicylates. Very
good correlation was found between salicylate
levels obtained with either the micro or the macro
method, using fingertip blood, plasma or venous
blood, following the ingestion of 10 grains of ac-
etylsalicylic acid.

HYDROLYSIS OF ACETYLSALICYLIC ACID IN THE BODY

Ever since acetylsalicylic acid was first used in
therapy, there have been some unanswered ques-
tions concerning its hydrolysis in the body. In
1946, Lester, Lolli and Greenberg,51 in a study of
the fate of this compound, demonstrated unchanged
acetylsalicylic acid in the plasma for a short period
following its ingestion. Smith and co-workers,85 in
1946, and other investigators were unable to find
unchanged acetylsalicylic acid in the plasma. To
aid in an in vivo and in vitro study of the hydroly-
sis of this compound, we prepared acetylsalicylic
acid labelled with C14 on the acetyl group.73 After
determining conditions for in vitro hydrolysis, we
administered the radioactive compound to rabbits
both intravenously and orally, and studied its
concentration in the plasma and urine. After in-
travenous injection, 90 per cent or more of the
compound was hydrolized within 30 to 40 minutes.
After oral administration, unhydrolyzed acetyl-
salicylic acid appeared in the plasma within 20 to
30 minutes, and persisted for about two hours.
Appreciable quantities of the compound were ex-
creted in the urine. More recently, Smith and his
colleagues have reported similar findings in hu-
man subjects.53

Salicylic acid labelled with C14 on the carboxyl
group was also synthesized, and the two radio-
active compounds were used to study the distribu-
tion of salicylates in rat tissues three hours after
administration.10 Every tissue examined contained
radioactivity, but the greatest concentration had oc-
curred in the blood, skeletal muscle and small in-
testine. Following the administration of acetyl-
labelled acetylsalicylic acid, a greater concentra-
tion of radioactivity was found in the expired CO-,
than in the urine. Following the administration of
carboxyl-labelled acetylsalicylic acid, the findings
were reversed. These compounds were used also

in an investigation of the permeability of the
synovial membrane in rabbits.66 It was observed
that both compounds moved freely from the blood
into the synovial cavity, and from the knee joint
back into the blood.

THE COMBINATION OF BICARBONATES WITH
ANTACIDS

It has long been known that salicylates are bet-
ter tolerated in large doses when taken with so-
dium bicarbonate. This beneficial effect was at-
tributed, for the most part, to a diminishing of ir-
ritation of the gastric mucosa and to the counter-
action of the acidosis formerly believed to be
present after large doses of salicylate. More re-
cently, interest has turned to the influence of bi-
carbonates on the concentration of salicylates in
blood and plasma. Many conflicting reports have
appeared on this latter subject.37’ 84’ 85> 88 In gen-
eral, the salicylate level may rise faster in the
presence of bicarbonate than after the ingestion of
salicylate alone. Three to six hours later, the level
drops below that found when the salicylate has
been given alone. When repeated doses are given,
as in rheumatic fever therapy, the maintenance
level is lower and urinary excretion is higher
when bicarbonates have been given in conjunction
with the salicylates. Another disadvantage of so-
dium bicarbonate is the fact that it may cause
alkalosis if given in repeated doses over a long
period of time.

In order to overcome these objections, we de-
cided to buffer acetylsalicylic acid with insoluble
antacids. In a previous study we had found that
dihydroxy aluminum aminoacetate (DAA) was an
ideal antacid.65 This compound buffered hydro-
chloric acid rapidly, had a prolonged action,
caused little or no constipation, and had a very
small particle size and a favorable taste. Various
mixtures were made, and it was found that the
buffering effect was dependent on the ratio of the
substances in the mixture as well as on the total
amount of buffering substance used. Combining
acetylsalicylic acid with DAA and magnesium car-
bonate, we effected a mixture which caused prac-
tically no gastric distress, even when given in
large amounts or over long periods of time. Add-
ing this buffer system in proper proportion to
acetylsalicylic acid resulted in a two-fold increase
in blood salicylate levels. The 10-minute salicylate
level following the ingestion of buffered acetyl-
salicylic acid, for example, exceeds the 20-minute
level for ordinary acetylsalicylic acid by more
than 20 per cent.64 Fremont-Smith28 used this
mixture in the management of patients with rheu-
matoid arthritis. He found that of 37 patients ac-
tually intolerant of acetylsalicylic acid, 26 (70 per
cent) tolerated the buffered acetylsalicylic acid
(Buiferin®) without exhibiting symptoms, in a
double blind trial. Eleven patients were intolerant

Vol. LII, No. 5

Journal of Iowa Medical Society

279

of both acetylsalicylic acid and Bufferin, but no
patient tolerant of acetylsalicylic acid was intoler-
ant of Bufferin.

RELATIONSHIP BETWEEN SALICYLATES AND
ABDOMINAL DISTRESS

Tebrock97 has noted that “the widespread use
and usefulness of aspirin are, paradoxically, one
reason why researchers have kept up an interest
in the limitations of its applications.” Since the
beginning of the century when Dreser20 and Binz5
suggested that the submucosal hemorrhages seen
in rheumatic fever may be due to salicylates, this
class of drug has often been incriminated as the
cause of a gastrointestinal toxicity ranging in its
effects from distress to ulcer and hematemesis.2
Hanzlik’s monograph35 contains many references
that had been made to this topic prior to 1927,
and Smith86 has reviewed the literature for the
period since 1927. Paul64 has shown that in a
large group of patients who were questioned about
their acetylsalicylic-acid habits, five per cent re-
ported abdominal distress. Other authors have
been in essential agreement, but have pointed out
that in patients with peptic ulcer, the frequency
may be as high as 30 per cent.

Paul believes that the causes of the gastric dis-
tress are gastric retention and spasm. The drug is
largely absorbed without hydrolysis, although
small amounts of salicylic acid, if produced, could
act as a gastric irritant. Yet, in a large series of
gastroscopies performed on normal individuals and
patients with peptic ulcers, Paul60 found no ev-
idence of gastritis, hemorrhage or hyperemia fol-
lowing the administration of various doses of the
drug.

A number of other authors have reported gas-
troscopies, on normal and on symptomatic patients,
either confirming Paul’s results,12’ 13’ 45’ 102 or re-
futing them.19- 42’ 56 It can be seen in the latter re-
ports, however, that the authors probably were re-
porting the effects of gastric suction that had been
used to empty the stomach. It is well known that
hemorrhages, erosions and even ulcers can be
caused by suction alone. Schindler77 states that
the presence of these lesions is not always a sign
of inflammation. This is clearly shown in a com-
parison of the results reported by Ruffin and
Brown,75 who used suction, and those of Fitzgib-
bon and Long,26 who employed gravity. The for-
mer reported pinpoint hemorrhages, but the latter
authors could find no hemorrhages. The phenom-
enon in which acetylsalicylic acid tablets adhere
to the lesser curvature and produce direct mucosal
sloughing, described by Douthwaite19 and by Muir
and Cossar,56 could occur only in a stomach de-
liberately kept aspirated. In a more recent report
by Rider, Moeller and Puletti69 on the effect of
salicylates on the gastric mucosa, the results from
the S.U.I. laboratory were again confirmed. These

authors concluded that no significant increase in
gastric acidity or occult blood occurred following
the ingestion of moderate doses of salicylate. No
direct evidence of mucosal irritation, hyperemia,
hemorrhage or ulceration was observed in gastro-
scopic examinations of 30 patients who had been
given salicylates, or in 10 patients who were
chronic users of salicylates.

SALICYLATES AND HEMATEMESIS

The problem of the patient who has undoubted
gastric hemorrhage during the period immediately
after acetylsalicylic acid administration is still un-
solved. Since the discovery of acetylsalicylic acid,
an irritating and erosive action of salicylate on
the gastrointestinal tract has been reported after
single doses as well as after prolonged admin-
istration of the drug. As early as 1899, Dreser20
stated that irritation and erosion of the stomach
mucosa occur from the local action of acetyl-
salicylic acid. Later, many workers have shown
that salicylates cause punctate hemorrhages and
ulcerations in the stomachs of dogs, rabbits and
other animals, regardless of whether the drug has
been given by mouth or intravenously. Occult
gastrointestinal bleeding and acute gastric hemor-
rhage have been reported frequently in associa-
tion with salicylate administration.1’ 8' 29> 47’ 78’ 95’ 96

Muir and Cossar57 gave two five-grain tablets
of acetylsalicylic acid to 20 patients with radiolog-
ically confirmed peptic ulceration, and found in-
creased gastric acidity, blood at gastric juice as-
piration, and occult blood in the stools in some pa-
tients. In reviewing the records of 166 patients
with hematemesis due to various causes, mostly
peptic ulcer, they found that 54 had taken acetyl-
salicylic acid within six hours prior to the hemor-
rhage. A patient who had experienced gastric
bleeding after taking small amounts of acetyl-
salicylic acid was examined gastroscopically by
Hurst and Lintott.42 They found that a few min-
utes after the patient swallowed two tablets of the
drug, the gastric mucosa adjacent to the tablets
had become intensely hyperemic, and there had
been an extravasation of blood. Using more re-
fined methods, Holt41 attempted to answer the
question of whether or not acetylsalicylic acid
causes gastrointestinal bleeding. He labelled red
cells with radioactive chromium (Cr51) and was
able to determine the extent to which occult blood
was lost in the stools. He found that 70 per cent
of the subjects who had taken acetylsalicylic acid
lost an average of 4.3 ml. /day. Control subjects
lost only 0.2 to 1.9 ml. of blood. It was assumed
that chronic ingestion of acetylsalicylic acid may
be accompanied by sufficient blood loss to induce
iron deficiency over prolonged periods.

In another study using Cr51, it was found that
small but statistically significant elevations of fecal
blood loss followed oral administration of acetyl-

280

Journal of Iowa Medical Society

May, 1962

salicylic acid, enteric-coated acetylsalicylic acid,
calcium acetylsalicylic acid, sodium salicylate or
phenacetin. Intravenous acetylsalicylic acid solu-
tion produced significant elevations of fecal blood
loss, but they were smaller than those produced
by oral administration. This would indicate that
local action on the gastric mucosa is not the sole
mechanism by which salicylates provoke bleed-
ing.34

Gastrointestinal hemorrhages and occult bleed-
ing are said to occur more often in individuals
who have acute or chronic peptic ulceration. In a
review of 103 patients who had been hospitalized
because of hematemesis and/or melena, salicylates
could be incriminated in over 40 per cent.1 It
would appear that massive hemorrhage caused by
acetylsalicylic acid ingestion should be one of the
common causes of hospital admissions because of
the universal use of this drug and because of the
high incidence of peptic ulcer. Patterson59 con-
cluded that approximately 12 per cent of all Amer-
icans have peptic ulcer at some time in their lives.
Although that figure is extremely high, it is sub-
stantiated by Palmer,58 who has commented that
autopsy studies indicate that peptic ulcer occurs
at some time in at least 12 per cent of all adults.
Robertson and Hargis,70 in a postmortem study of
2,000 cases, found evidence of duodenal ulceration,
either healed or active, in 11.85 per cent of them.
Not only is peptic ulcer very common, but upper
gastrointestinal hemorrhage is a frequent com-
plication of that lesion. Ivy, Grossman and Bach-
rach43 reported that 72 per cent of upper gastro-
intestinal bleeding is caused by peptic ulceration.
Approximately 25 per cent of peptic ulcer patients
bleed at one time or another, and similarly, ap-
proximately one ulcer case in every four is admit-
ted to a hospital because of bleeding.

Over a four-year period, 60,614 new patients
were admitted to the State University of Iowa
Hospitals, and another 89,295 were seen in the
various outpatient clinics, a total of 149,909 cases.
Of those patients, 96 were admitted for massive
gastrointestinal bleeding, but no cause for the
bleeding was found. Many cases of massive bleed-
ing were admitted, but the diagnoses in those pa-
tients were obvious or were found shortly after
admission. Of the 96 individuals just referred to,
exact diagnoses were finally established in 89,
either after they had been in the hospital for pro-
longed stays, or on subsequent visits. At least 50
per cent were found to have malignancies; 25 per
cent were found to have peptic ulcer; and the
other 25 per cent were found to be bleeding from
a variety of causes such as trauma, hemangiomas,
unexplained inflammation, ulcerative colitis, etc.
The seven others of the original 96 are still living,
but no cause for their massive bleeding has even
been found. Only four of that group had sug-
gestive histories of taking acetylsalicylic acid just
prior to or during the time of hemorrhage. The

hospital records of 200 patients diagnosed as hav-
ing rheumatoid or degenerative arthritis were re-
viewed. All of them had been admitted prior to
the use of steroids or were not treated with the
corticosteroids. Only patients receiving at least 3
Gm. of acetylsalicylic acid daily were included in
that series. None of those patients had any ev-
idence of gastrointestinal bleeding, had at most
only traces of occult blood in the stools, and had
an average hemoglobin level of nearly 11 Gm.

Since the advent of the corticosteroids in 1950,
it is probable that peptic ulceration may have
increased by 20 to 60 fold over the expected nor-
mal incidence in people undergoing therapy with
those hormones. Of 169 patients treated with hor-
mones for rheumatoid arthritis, 18.2 per cent of
the men and 8.7 per cent of the women had peptic
ulcer. No ulcers occurred in patients receiving
acetylsalicylic acid.48 Symptoms of peptic ulcer in
patients receiving corticosteroids are sometimes
so masked that the first indications may be hemor-
rhage or perforation.9- 17- 21 > 33> 38> 44- 48’ 81’ 100 Se-
rious gastrointestinal symptoms occur in 25 per
cent of rheumatoid arthritics treated with mod-
erate to large doses of adrenocortical hormones,
and 12 per cent of those patients develop peptic
ulcer either with or without massive hemorrhage
or perforation.22- 39

If salicylates — particularly in the form of acetyl-
salicylic acid — are as potent gastric irritants as
they have been reported to be in the literature,
then patients who developed peptic ulcer and/or
hemorrhage during steroid therapy should have
more dyspepsia or bleeding when given adequate
doses of salicylates over prolonged periods of time.
Since 1953, we have treated many rheumatoids
who had previously had either proved peptic ul-
cers or massive bleeding during steroid therapy,
giving them from 3 to 6 Gm. of acetylsalicylic acid
per day. None of those individuals have had fur-
ther episodes of bleeding or severe dyspepsia. Bara-
gar and Duthie3 have followed the mean level of
hemoglobin in a group of rheumatoid arthritics
treated with salicylates over a six-year period.
They have found that in 31 individuals who had
had only occasional salicylates the average hemo-
globin level at admission was 87.2 per cent, and
six years later it was 97.4 per cent. In 75 patients
who received 2.6 to 4.0 Gm. of acetylsalicylic acid
per day, the mean hemoglobin level at the time
of hospital admission was 83.0 per cent, and that
six years later it rose to 92.1 per cent. They con-
cluded that most patients with rheumatoid ar-
thritis can tolerate acetylsalicylic acid without an
increase in anemia, and that the dangers of caus-
ing peptic ulceration or precipitating hemorrhage
appear to have been greatly exaggerated.

The causal relationship between acetylsalicylic
acid and bleeding can best be summed up by quot-
ing an editorial comment from the year book of
medicine:105 “Aspirin being the common drug it is,

Vol. LII, No. 5

Journal of Iowa Medical Society

281

it may be as easy to obtain a history of aspirin
ingestion as it is to obtain a history of some sort
of emotional upset in the hours preceding a gastro-
intestinal episode. Elaborate control series and
checks are therefore necessary before definite con-
clusions can be reached. Furthermore, if patients
take aspirin, there usually is some reason: a

headache or cold that may be more to blame for
activation of the ulcer symptoms than the aspirin.
It is even possible that patients who have already
started to bleed take aspirin because the blood loss
is making them feel poorly.”

RECENT WORK WITH SALICYLATES AT S.U.I.

The widest use of salicylate, especially acetyl-
salicylic acid, is for the relief of pain of moderate
intensity, such as headache and muscular pain.
The way in which salicylates alleviate pain is un-
known. Many attempts have been made to pro-
duce uniform pain of low intensity, but none of
the methods used have proved successful. We have
used many of these technics and have devised
new ones, but all have culminated in negative
results. As there is no method for producing a
standard low-intensity pain, it is difficult to screen
the analgesic effect of salicylates or similar me-
dicaments. We therefore must fall back upon clin-
ical experience and patient acceptance in deter-
mining the extent of analgesia. Acetylsalicylic acid
exerts its analgesic action regardless of whether
the pain is localized or widespread in origin. One
of the beneficial effects of salicylates is that anal-
gesic doses of 5 to 10 grains given every four
hours do not cause central nervous system changes
like those seen after the administration of nar-
cotics. Acetylsalicylic acid has been used in every
condition where pain is present, and to name those
conditions would necessitate compiling a list near-
ly as long as the index of any textbook of med-
icine.

Acetylsalicylic acid has been prescribed in a
variety of dermatologic conditions, with results
ranging from poor to excellent. For many years
antipyretic agents, including nupercaine, surfo-
caine, benzocaine, etc., have been used topically.
In addition, a host of antihistaminics have been
used topically for the same purpose. Both types of
compounds, unfortunately, have proved to be
relatively high sensitizers. When topical sensitiza-
tion occurs, it precludes the use of these drugs for
internal medication.

At the State University of Iowa Hospitals, Buf-
ferin has been used by the dermatologists to ob-
tain both analgesia and relief from itching. In
acute pruritis and in the subacute and chronic
dermatoses, they prescribe 10 grains of Bufferin
every four hours during the day, and 10 grains at
bedtime. In some patients, added doses are given
if necessary. The more acute the dermatitis, the
more important does the antipruritic effect of
acetylsalicylic acid become.

The hypnotic effect of acetylsalicylic acid has
not been recognized. As a result of the race among
organic chemists to synthesize more and more sed-
atives, this type of medication has become very
popular in recent years. Most of the sedatives ex-
hibit side effects, many of which are mild and of
no consequence, but others are severe and cause
serious results. Ten grains of acetylsalicylic acid
given an individual at bedtime will afford enough
relaxation to allow him to fall asleep. The mode
of action is probably not on the higher centers,
but merely relieves his mild aches or pains, and
allows relaxation and normal sleep to ensue. We
have found that this works best in individuals
having functional gastrointestinal distress, joint or
muscular aches, fever from infections, mental up-
sets or peptic ulcer. In many of our patients, we
try acetylsalicylic acid before resorting to the
routine sedatives.

MISCELLANEOUS USES FOR THE DRUG

The effect of salicylates in lowering the tem-
perature of a febrile patient is an ancient observa-
tion that has been supported by extensive clin-
ical and experimental evidence. With the intro-
duction of antibiotics, there has come to be less
emphasis on drugs that have an antipyretic effect.
The antibiotics have controlled many of the bac-
terial infections, but as yet they have had no effect
on the viral diseases. Anterior poliomyelitis oc-
curs in epidemics each year in the Midwest. Al-
though the new vaccines may prevent the spread
of the disease or reduce the paralysis, we have no
specific drug with which to treat the malady. The
only drug that we have used routinely in these
patients is acetylsalicylic acid. Whenever the tem-
perature rises above 104°F., ten grains of Buf-
ferin is prescribed. This medication can be repeat-
ed frequently during the first week or 10 days of
illness, and indeed can be given several times a
day. Ten grains of Bufferin can also be given the
patient in the evening to induce sleep. Headache,
one of the commonest symptoms of the disease,
can be relieved by means of acetylsalicylic acid.

The most distressing complications of chronic
illnesses such as chronic spinal or bulbo-spinal
poliomyelitis, paraplegia or hemiplegia are the in-
fections that occur in the genitourinary tract, and
the formation of bladder or renal stones in con-
sequence of immobilization or long-term catheter-
ization. Prien67 reported that recurring stones re-
sulting from immobilization could be prevented
through the administration of salicylates or sal-
icylamide. Since late in 1954, we have prescribed
15 grains of Bufferin to be given routinely, three
times a day, to such patients as soon as they are
admitted. This dose of Bufferin is continued as
long as there is danger of stone formation. Al-
though we have not prevented the occurrence of
bladder stones around the tip of the catheter, we
feel that we have reduced the incidence of both

282

Journal of Iowa Medical Society

May, 1962

renal and bladder stones enough to justify con-
tinuing this type of therapy.

The greatest use of acetylsalicylic acid is in the
treatment of the arthritides. Its effect in rheumat-
ic fever has been well established and needs no
further elaboration.11- 32- 40- 54- 68- 82- 91 Fibrositis, a
syndrome of soft-tissue aching and stiffness, is
usually caused by tension, anxiety, emotional
stress and changes in climatic conditions. The pain
and stiffness are usually worse after inactivity,
overactivity or fatigue. It is relieved by mild ac-
tivity, heat and salicylates. Myalgic spots (trigger
points) can be sought, and if found, the symptoms
of this syndrome can be relieved by spraying with
ethyl chloride or by injection with local anesthet-
ics or normal saline.15 Bufferin is the drug of
choice, and is very effective in doses of 0.6 Gm.
three to five tunes a day. On the other hand, the
so-called “psychogenic rheumatism” can be dif-
ferentiated from fibrositis, since little or no relief
results in such cases from the use of Buffer-

72, 87, 93

Salicylates were recommended for the treat-
ment of gout and podagra as early as in the first
century by both Dioscorides and Quintus Serenus
Samonicus.18- 83 See80 reported reduction in the
size of tophi and increase in urate excretion dur-
ing salicylate administration as long ago as 1887.
Acetylsalicylic acid and sodium salicylate act as
uricosuric drugs when administered in large doses.
Although they reduce tophi and increase urate
excretion, the high blood levels of 30 to 40 mg.
per cent that must be maintained for this purpose
cause tinnitus and other symptoms of salicylism.
Since the development of the newer uricosuric
agents with fewer side effects, salicylates haven’t
needed to be resorted to in the treatment of gout.89
The antagonistic effects of salicylates on the uri-
cosuric action of probenecid, sulfinpyrazone and
zoxazolamine are still open to question and re-
quire further investigation.4- 71- 89- 90- 103 Small
doses of salicylates do not interfere with the uri-
cosuric drugs. In gouty arthritis, relief can be ob-
tained through an occasional 0.6 Gm. of Bufferin.

ACETyLSALICyUC ACID IN ARTHRITIS

In degenerative or osteoarthritis and in traumat-
ic arthritis, the most effective drug is acetylsalicyl-
ic acid. It can be given to elderly patients with
osteoporosis, hypertension, or cases of heart fail-
ure or peripheral vascular disease, without any
untoward side effects. Bufferin doses of 0.6 Gm.
can be prescribed for the relief of stiffness and
pain. It is always safer to teach the patient to
take two Bufferin tablets to relieve symptoms as
they occur, than to direct that he take it regularly
three, four or five times a day. Salicylates can be
used in conjunction with phenylbutazone or other
drugs that these elderly patients may need.

Rheumatoid arthritis is only one part of a gen-
eralized disease in which the major histologic

changes occur in synovial membranes, cartilage
and other structures in and about the joints.62
There are no specific remedies that will cure or
arrest the disease, and therefore treatment is di-
rected toward (1) suppression of acute exacerba-
tion, (2) maintenance of function, (3) reduction of
pain, (4) prevention of marked muscle atrophy
and shortening, and (5) the possibility of continu-
ing the activities of daily living. The basis of all
treatments for rheumatoid arthritis is the main-
tenance of mobility through adequate motion, and
the relief of pain by means of simple analgesics
and/or physical therapy of the type that can be
carried out at home. Despite all the newer so-
called miracle drugs, salicylates remain the most
effective antirheumatic and analgesic agents in
the treatment of arthritis.61 In the acute stage of
the disease, when there are symptoms such as
swelling, redness, pain and heat in the joints,
salicylates are given orally in the form of acetyl-
salicylic acid. We usually prescribe 0.6 Gm. of
Bufferin every three hours until the acute symp-
toms have subsided, and then reduce the dose ac-
cordingly. Later, we give 0.6 Gm. on arising, to
overcome stiffness, and then before each physical
therapy procedure, to prevent excessive pain. Pa-
tients are taught to ask for Bufferin only when
they have stiffness or excessive pain. Arthritics
who are willing to endure some pain will usually
remain ambulatory, rather than be chair- or bed-
ridden. Should steroids be necessary, they are al-
ways given in conjunction with salicylates. For a
patient in an acute exacerbation, we might pre-
scribe 1.0 mg. of Prednisone six to eight times a
day (a total of 6 or 8 mg.). Bufferin, 0.6 Gm., is
given in the morning for stiffness, and as many
times throughout the day as needed for pain.
When the pain is ameliorated so that only three or
four doses of Bufferin are needed, the steroid is
reduced 1 mg. at a time. Relying on the salicylate
rather than on the steroid, we reduce the Pred-
nisone to the lowest possible dose, while letting
the dose of salicylate fluctuate from day to day.
Bufferin is never given on a regular schedule.
Rather, it is used only when the pain becomes
unbearably severe.

Finally, it must be recognized that individuals
who have “burned-out” arthritis or who are in a
remission still have pain. Pain during these phases
does not represent activity of rheumatoid disease,
but merely is a consequence of the ravages of the
process. Loss of cartilage, fibrosis, muscle shorten-
ing, partially destroyed tendons, subluxation and
contractures — all of these cause pain when the pa-
tient attempts to move an extremity. These cases
do not need steroids, but rather need salicylates
and physical therapy. It is this group who, when
given steroids, either increase the dose or take
the hormones over extended periods of time and
develop serious side effects. If such patients are
taught to take salicylates instead of steroids, to as-

Vol. LII, No. 5

Journal of Iowa Medical Society

283

sist them in ambulation, they will take the steroid
less frequently, with more benefit and with fewer
complications.63

CONCLUSION

A complete discussion of all the conditions for
which acetylsalicylic acid has been recommended
would be endless and boring. We can think of a
no more fitting conclusion for our efforts than the
following quotation from an editorial comment in

THE YEAR BOOK OF DRUG THERAPY: 104

“WHAT A DRUG IS THIS ASPIRIN!— The old
reliable antiphlogistic in acute rheumatic fever,
still holding its own against the new pituitary-
adrenal hormonal compounds; the universal anti-
pyretic; sheet-anchor therapeutic agent for rheu-
matoid arthritis and used in carload lots by creak-
ing old osteoarthritics; champion of them all
against general aches-and-pains; indispenable po-
tion for the dysmenorrheic woman; splendidly
effective uricosuric agent in gout; serious dis-
turber of acid-base balance in excessive amounts;
chief among the killers of infants who get at the
household medicine cabinet; severe gastric ir-
ritant upon occasion; potential dealer of death to
the occasional one who is hypersensitive to it;
most used pharmacotherapeutic agent in the world.
WHAT A DRUG!”

REFERENCES

1. Alvarez, A. S., and Summerskill, W. H. J.: Gastrointes-
tinal hemorrhage and salicylates. Lancet, 2:920-925, (Nov. 1)
1958.

2. Jones, F. Avery: Modern Trends in Gastroenterology,
New York, Paul B. Hoeber, 1952.

3. Baragar, F. D., and Duthie, J. J.: Importance of aspirin
as a cause of anaemia and peptic ulcer in rheumatoid arthritis.
Brit. Med. J. 1:1106-1108, (Apr. 9) 1960.

4. Bauer, W., and Singh, M. M. : Management of gout. New
England J. Med., 256:171-176, (Jan. 24) 1957; 256:214-219,
(Jan. 31) 1957.

5. Binz, C.: Vorlesungen ueber Pharmakologie. Herschwald,
Berlin, 1891.

6. Bradley, W. B.: Method for rapid determination of sali-
cylates. Proc. Soc. Exper. Biol. & Med., 35:1-4, (Oct.) 1936.

7. Brodie, B. B., Undenfriend, S., and Coburn, A. F.: Deter-
mination of salicylic acid in plasma. J. Pharmacol. & Exper.
Therap., 80:114-117, (Jan.) 1944.

8. Brown, R. K., and Mitchell, N.: Influence of some of
salicyl compounds (and alcoholic beverages) on natural his-
tory of peptic ulcer. Gastroenterology 31:198-203, (Aug.)
1956.

9. Bunim, J J.: Clinical uses and hazards of adrenal ster-
oids and their analogues in management of rheumatic dis-
eases. Bull. New York Acad. Med., 33:461-473, (July) 1957.

10. Burnham, E. M., Paul, W. D., and Routh, J. I.: Dis-
tribution of C14 labelled salicylates in rat tissues. Proc. Iowa
Acad. Sci., 63:403-409, (Dec. 6) 1956.

11. Bywaters, E. G. L.: Treatment of rheumatic fever. Cir-
culation, 14:1153-1158, (Dec.) 1956.

12. Caravati, C. M.: Gastric endoscopic and secretory find-
ings during salicylism. Gastroenterology, 6:7-8, (Jan.) 1946.

13. Caravati, C. M., and Cosgrove, E. F.: Salicylate toxicity:
probable mechanism of its action. Ann. Int. Med., 24:638-
642, (Apr.) 1946.

14. Coburn, A. F.: Salicylate therapy in rheumatic fever:
rational technique, Bull. Johns Hopkins Hosp., 73:435-464,
(Dec.) 1943.

15. Copeman, W. S. C.: Rheumatic diseases, with special
reference to non-articular rheumatism. New Zealand M. J..
55:102-107, (Apr.) 1956.

16. Cosmides, G. J., Stamler, F. W., and Miya, T. S.: Colori-
metric comparison of plasmasalicylate levels following oral
administration of certain salicylates to rabbits. J. Am. Pharm.
A. (Sc. Ed.), 45:16-20, (Jan.) 1956.

17. Davison, S.: Massive gastrointestinal hemorrhage during
prednisteroid therapy for rheumatoid arthritis. New York J.
Med., 57:1758-1760, (May 15) 1957.

18. Dioscorides: Opera quae extant omnia; Lib. I., Cap. 136
(Transl. by Janus Antonius Saracenus.), Frankfurt am Main,
Andrea Wechel Heirs, 1598.

19. Douthwaite, A. H., and Linott, G. A. M. : Gastroscopic

observation of effect of aspirin and certain other substances
on stomach. Lancet, 2:1222-1225, (Nov. 26) 1938.

20. Dreser, H.: Pharmakologisches uber Aspirin ( Acetyl -
salicylsaure) . Pflug. Arch. ges. Physiol., 76:306-318, 1899.

21. Dubois, E. L., Bulgrin, J. G., and Jacobson, G.: Cortico-
steroid-induced peptic ulcer: serial roentgenological survey
of patients receiving high dosages. Am. J. Gastroenterol.,
33:435-453, (Apr.) 1960.

22. Edgcomb, J. H.: On development of peptic ulcers in
patients treated with prednisone or prednisolone. Schweiz.
Ztschr. f. Path. u. Bakt., 21:363-372, 1958.

23. Feser and Friedberger: Versuche uber die Wirkungen
der Salicylsaure. Arch. wiss. ensch. u. prakt. Thierh. Berl.
1:156-221, 1875; 2:133-219, 1876.

24. Fiessinger, N., and Debray, J.: Evolution de la salicyl-
emie apres ingestion de salicylate de soude chez le sujet nor-
mal. Compt. rend. Soc. de biol. Par. 1922, 87:336-337, (July)
1922.

25. Filippi, E., and Nesti, G.: Ueber die Ausscheidung des
Aspirins. Allg. med. Centre. -Ztg. Berl. 1902, 71:613.

26. Fitzgibbon, J. H., and Long, G. B.: Gastroscopic study
of healthy individuals: preliminary report. Gastroenterology,
1:67-71, (Jan.) 1943.

27. Floeckinger, F. C.: Experimental study of aspirin, new
salicylic-acid preparation. Med. News, 75:645-647, (Nov. 18)
1899.

28. Fremont-Smith, P.: Bufferin in management of rheuma-
toid arthritis. J.A.M.A., 158:386-388, (June 4) 1955.

29. Gelfand, M. L., and Goodkin, L.: Drug-induced gastro-
intestinal bleeding. New York J. Med., 58:2381-2384, (July
15) 1958.

30. von Gerhardt, C.: Untersuchungen uber die wasser-
freien organischen Sauren. Liebigs Ann., 87:149-178, 1853.

31. Gerland, H.: New formation of salicylic acid, (From
a letter of Dr. Kolbe to Dr. Hoffman). J. Chem. Soc., 5:133,
1852.

32. Ghita, N.: Prevention of relapses in rheumatism. Ru-
manian M. Rev., 2:48-50, (Apr. -June) 1958.

33. Granirer, L. W.: Sudden perforation of asymptomatic
duodenal ulcer in patient on prednisone therapy. New York
J. Med., 56:2855-2856, (Sept. 15) 1956.

34. Grossman, M. I., Matsumoto. K. K., and Lichter, R. J.:
Fecal blood loss produced by oral and intravenous adminis-
tration of various salicylates. Gastroenterology, 40:383-388,
(Mar.) 1961.

35. Hanzlik, P. J.: Actions and use of salicylates and cin-
chophen in medicine. Medicine, 5:197-373, (Aug.) 1926.

36. Hanzlik, P. J., Scott, R. W., and Thoburn, T. W.: Sali-
cylates v. excretion of salicyl in urines of rheumatic and
non-rheumatic individuals. J. Pharm. & Exper. Therap.,
9:247-267, (Feb.) 1917.

37. Herrera-Ramos, F.: Estudio experimental en el perro
de la circulacion sanqulnea del salicilato de sodio. Arch,
urug. de med. cir. y especialid., 11:714-719, (Dec.) 1937.

38. Hess. E. V., and MacPherson, M. E.: Perforated duodenal
ulcer complicating prednisolone therapy. Brit. M. J., 1:271,
(Feb. 2) 1957.

39. Hilbish, T. F., and Black, R. L. : X-ray manifestations
of peptic ulceration during corticosteroid therapy of rheuma-
toid arthritis. Arch. Int. Med., 101:932-942, (May) 1958.

40. Holt, K. S.: Salicylates in rheumatic fever; difficulties
experienced in treating children with large doses. Lancet,
2:1197-1199, (Dec. 11) 1954.

41. Holt, P. R.: Measurement of gastrointestinal blood loss
in subjects taking aspirin. J. Lab. & Clin. Med., 56:717-726,
(Nov. '3) 1960.

42. Hurst, A., and Lintott, G. A. M.: Aspirin as cause of
haematemesis: clinical and gastroscopic study. Guy’s Hosp.
Rep., 89:173-176, (Apr.) 1939.

43. Ivy, A. C., Grossman, M. I., and Bachrach, W. H.:
Peptic Ulcer. Phila., The Blakiston Co., 1950.

44. Kammerer, W. H., Frieberger, R. H., and Rivelis, A. L. :
Peptic ulcer in rheumatoid patients on corticosteroid therapy:
clinical, experimental and radiologic study. Arth. & Rheumat.,
1:122-141. (Apr.) 1958.

45. Katz, J., Dryer, R. L., Paul, W. D., and Routh, J. I.:
Effect of acetylsalicylic acid on gastric mucosa of Shay rat.
Am. J. Digest. Dis., 16:88-91, (Mar.) 1949.

46. Keller, W. J., Jr.: Rapid method for determination of
salicylates in serum or plasma. Am. J. Clin. Path., 17:415-
417, (May) 1947.

47. Kelly, J. J., Jr.: Salicylate ingestion: frequent cause
of gastric hemorrhage. Am. J. M. Sc., 2 3 2:119-128, (Aug.)
1956.

48. Kern, F., Jr., Clark, G. M., and Lukens, J. G.: Peptic
ulceration occurring during therapy for rheumatoid arthritis.
Gastroenterology, 33 : 25-33, (July) 1957.

49. Kolbe, H.: Ueber Synthese der Salicylsaure. Liebigs
Ann., 113:125-127, 1860.

50. Kolbe, H., and Lautemann, E.: Ueber die Constitution
und Basicitate der Salicylsaure. Liebigs Ann., 115:157-206,
1860.

51. Lester, D., Lolli, G., and Greenberg, L. A.: Fate of
acetylsalicylic acid. J. Pharmacol. & Exper. Therap., 87:329-
342, (Aug.) 1946.

52. MacLagan, T.: Treatment of acute rheumatism by

salicin. Lancet, 1:342-343, (Mar. 4) 1876; 1:383-384, (Mar.
11) 1876.

53. Mandel, H. G., Cambosos, N. M., and Smith, P. K.:
Presence of aspirin in human plasma after oral administra-
tion. J. Pharmacol. & Exper. Therap., 112:495-500, (Dec.)
1954.

284

Journal of Iowa Medical Society

May, 1962

54. Massell, B. F.: Diagnosis and treatment of rheumatic
fever and rheumatic carditis. M. Clin. North America,
42:1343-1360. (Sept.) 1958.

55. Mosso, U.: Quantitative Untersuchungen uber die Aus-
scheidung der Salicylsaiire und der Umwandlungsprodukte
des Benzylamins aus dem thierischen Organismus. Arch. f.
exper. Path. u. Pharmakol. Leipz., 26:267-278, 1889.

56. Muir, A., and Cossar, I. A.: Aspirin and ulcer. Brit.
M. J., 2:7-12, (July 2) 1955.

57. Muir, A., and Cossar, I. A.: Aspirin and gastric haem-
orrhage. Lancet, 1:539-541, (Mar. 14) 1959.

58. Palmer, W. L.: Stomach and military service. J.A.M.A.,
119:1155-1159, (Aug. 8) 1942.

59. Patterson, M. : Incidence of peptic ulcer. New Orleans
M. & S. J., 96:570-591, (June) 1944.

60. Paul, W. D.: Effect of acetylsalicylic acid (aspirin) on
gastric mucosa; gastroscopic study. J. Iowa M. Soc., 33:155-
158, (Apr.) 1943.

61. Paul, W. D.: Medical rehabilitation of rheumatoid ar-
thritis. J. Iowa M. Soc., 49:203-206, (Apr.) 1959.

62. Paul, W. D.: Rehabilitation in rheumatoid arthritis.
Southern M. J., 53:492-496, (Apr.) 1960.

63. Paul, W. D.: Systemic manifestations of rheumatoid
arthritis (rheumatoid disease) accentuated by steroid ther-
apy. J. Iowa M. Soc., 51:205-216, (Apr.) 1961.

64. Paul, W. D., Dryer, R. L., and Routh, J. I.: Effect of
buffering agents on absorption of acetylsalicylic acid. J. Am.
Pharm. A. (Sc. Ed.), 39:21-24, (Jan.) 1950.

65. Paul, W. D., and Rhomberg, C.: Medical management
of uncomplicated peptic ulcer. J. Iowa M. Soc., 35:167-185,
(May) 1945.

66. Paul, W. D., and Routh, J. I.: Studies on permeability
of synovial membrane. Proc. Int. Cong. Phys. Med., pp. 208-
213, 1952.

67. Prien, E. L., and Walker, B. S.: Salicylamide and acetyl-
salicylic acid in recurrent urolithiasis. J.A.M.A., 160:355-
360, (Feb. 4) 1956.

68. Rantz, L. A.: Treatment of rheumatic fever. Anti-
biotic Med. & Clin. Therapy, 4:748-754, (Nov.) 1957.

69. Rider, J. A., Moeller, H. C., and Puletti, E. J.: Effect
of salicylates on gastric mucosa. Bull. Gastroint. Endoscopy,
8:5-9, (Feb.) 1962.

70. Robertson, H. E., and Hargis, E. H.: Duodenal ulcer:
anatomic study. M. Clin. North America, 8:1065-1092, (Jan.)
1925.

71. Robinson, W. D.: Current status of treatment of gout.
J.A.M.A., 164:1670-1674, (Aug. 10) 1957.

72. Rosenberg, E. F.: Classification and management of
fibrositis. M. Clin. North America, 42:1613-1627, (Nov.) 1958.

73. Routh, J. I., Knouse, R. W., and Paul, W. D.: Studies
on hydrolysis of acetyl-l-C14 salicylic acid. Proc. Iowa Acad.
Sci., 62:268-272, (Dec. 15) 1955.

74. Routh, J. I., Paul, W. D., Arredondo, E., and Dryer,
R. L. : Semimicro method for determination of salicylate lev-
els in blood. Clin. Chem., 2:432-438, (Dec.) 1956.

75. Ruffin, J. M., and Brown, I. W.: Significance of hemor-
rhagic or pigment spots as observed by gastroscopy. Am. J.
Digest. Dis., 10:60-63, (Feb.) 1943.

76. Sauerland, F.: Uber die Resorption von Arzneimitteln
aus Salben bei anwendung verschiedener Salbengrundlagen.
Biochemistry Ztschr. Berl., 40:56-82, (Feb.) 1912.

77. Schindler, R.: Gastroscopy, Second Edition. Chicago,
Univ. of Chicago Press, 1950.

78. Schneider, E. M. : Aspirin as gastric irritant. Gastro-
enterology, 33:616-620, (Oct.) 1957.

79. Scott, R. W., Thoburn, T. W., and Hanzlik, P. J.: Sali-
cylates: IV. Salicylate in blood and joint fluid of individuals

National Blue

More than $816,012,000 was paid by the 75 Blue
Shield Plans for care rendered members in 1961,
and during the same period the medical-surgical
Plans recorded an enrollment gain of more than
2,037,000 persons, the National Association an-
nounced in Chicago on April 16.

Total membership in the Blue Shield Plans
located in North America reached 49,122,164 as of
December 31, 1961, which represents an enrollment
of 25 per cent of the total United States population,
and just over 15 per cent of the total Canadian
population.

Last year’s payments to the medical profession in
behalf of members represented nearly 89 per cent
of the total income of all Plans. Meanwhile, the
Plans devoted less than 10 per cent of total income
for administrative expenses.

receiving full therapeutic doses of drug. J. Pharm. & Exper.
Therap., 9:217-225, (Jan.) 1917.

80. See, G.: Etudes sur l’acide salicylique et les salicylates:
traitement du rhumatisme aigu et chronique, de la goutte,
et de diverses affections du systeme nerveux sensitif par les
salicylates. Bull. Acad. Med., Paris, 2.S., 6:689-706; 717-754,
1877.

81. Segal, H.: Perforated gastric ulcer during prednisolone
therapy. M. J. Australia, 1:184-185, (Feb. 8) 1958.

82. Sen, S.: Management of rheumatic fever. J. Indian
M. A., 30:153-155, (Mar. 1) 1958.

83. Serenus Samonicus, Quintus, Commentary on Celsus,
Aulus Cornelius, De Re Medica, libri octo eruditissimi, Haga-
noae, 1528.

84. Smith, P. K.: Salicylate metabolism in normal sub-
jects. News Letter, A.A.F. Rheumatic Fever Control Program.
2:8-11, 1945.

85. Smith, P. K., Gleason, H. L., Stoll, C. G., and Ogor-
zalek, S.: Studies on pharmacology of salicylates. J. Phar-
macol. & Exper. Therap., 87:237-255, (July) 1946.

86. Smith, P. K. : Certain aspects of pharmacology of sali-
cylates. J. Pharmacol. & Exper. Therap., 97:353-382, (Dec.
pt. 2) 1949.

87. Smith, R. T.: Successful therapy of fibrositis. J. Am.
Geriatrics Soc., 6:147-156, (Feb.) 1958.

88. Smull, K., Wegria, R., and Leland, J.: Effect of sodium
bicarbonate on serum salicylate level during salicylate ther-
apy of patients with acute rheumatic fever. J.A.M.A.,
125:1173-1175, (Aug. 26) 1944.

89. Smyth, C. J., Frank, L. S., and Huffman, E. R.: Urate
diuretic therapy in chronic gout. A.I.R., 3:3-24, (Mar.) 1960.

90. Stillman, J. S.: Current therapeutics, CXX. Probenecid,
Practitioner, 179:719-724, (Dec.) 1957.

91. Stollerman, G. H.: Rheumatic fever. A.M.A. Arch. Int.
Med., 98:211-220, (Aug.) 1956.

92. Stone, E. : Account of success of bark of willow in cure
of agues. Philos. Trans., 53:195-200, 1763.

93. Stone, K.: Differential diagnosis of lumbago. Practi-
tioner, 177:100-103, (July) 1956.

94. Strieker: Ueber die Resultate der Behandlung der Poly-
arthritis rheumatica mit Salicylsaure. Berl. klin. Wschr.,
13:1-2, 15-16, 99-103, 1876.

95. Stubbe, L.Th. F.L.: Occult blood in faeces after admin-
istration of aspirin. Brit. M. J., 2:1062-1066, (Nov. 1) 1958.

96. Summerskill, W. H. J., and Alvarez, A. S.: Salicylate
anaemia. Lancet. 2:925-928, (Nov. 1) 1958.

97. Tebrock, H. E.: Gastric tolerance for aspirin and buf-
fered aspirin. Indust. Med., 20:480-482, (Oct.) 1951.

98. Thoburn, T. W., and Hanzlik, P. J.: Salicylates: II.
methods for quantitative recovery of salicyl from urine and
other body fluids. J. Biol. Chem., 23:163-180, 1915.

99. Trinder, P. : Rapid determination of salicylate in bio-
logical fluids. Biochem. J., 57:301-303, (June) 1954.

100. Weir, A. B., Jr.: Systemic effects of prolonged use of
corticosteroids. J. Tennessee M. A., 51:395-401, (Oct.) 1958.

101. Wohlgemut, J.: Ueber Aspirin ( Acetylsalicylsaure) .

Ther. Mh. (Halbmh.), 13:276-278, 1899.

102. Wolff, S., and Wolff, H. G.: Human Gastric Function.
Oxford, London Univ. Press, 1943.

103. Wyngaarden, J. B.: Role of kidney in pathogenesis
and treatment of gout. Arth. & Rheumat., 1:191-203, (June)
1958.

104. Yearbook of Drug Therapy, 1955-1956. Chicago, Year-
book Publ., p. 368.

105. Yearbook of Medicine, 1956-1957. Chicago, The Year-
book Publ., p. 518.

Shield Statistics

“Blue Shield’s contribution toward helping an
important segment of the public meet its health
care needs is evidenced succinctly in this 1961
report,” the National Association of Blue Shield
Plans reported.

“Blue Shield payments to doctors have gone
from $165,000,000 in 1951 to the 1961 figure of
over $816,012,000, proving the ability of these med-
ical-surgical Plans to provide coverage that keeps
pace with the dramatic advances in medical sci-
ence.”

“And the fact that in the relatively short period
of 15 years Blue Shield has attained nearly 50 mil-
lion members reflects the public and industry ac-
ceptance and confidence in the programs offered
by the Plans,” the National Association’s report
concluded.

A Case Report

Congenital Megacolon

(Hirschsprung's Disease),

Associated With

Hypoproteinemia and Edema

R G. BERGGREEN, M.D.

Mason City

Griffin1 recently reported a case of congenital
megacolon (Hirschsprung’s disease) associated
with hypoproteinemia and edema. He noted that
a review of the literature had failed to disclose any
mention of the association between the two con-
ditions.

This paper will report a similar case, and will
indicate that the association is perhaps not rare
and that the possibility of congenital megacolon
must be considered in an edematous infant, even
in the absence of signs of obstruction.

CASE REPORT

T.A.M., a Caucasian female, was delivered in
another hospital on June 20, 1961. Her birth weight
was 7 lbs. 9 oz., and she was the tenth child of a
41-year-old father and a 39-year-old mother in
good health. The first eight children are living
and well. The ninth had died at the age of two
months of mucoviscidosis, confirmed by post-
mortem examination.

Although the patient was irritable in the new-
born nursery, and vomited occasionally, she was
discharged with her mother after five days, on an
evaporated milk-Dextri Maltose formula. She then
weighed 7 lbs. 10 oz.

During the following three weeks, the baby
gained slowly, but the parents were concerned
about what they considered unusual irritability
and occasional distention of the abdomen. The
stools, however, were regarded as normal. The
parents later recalled that during this interval
they first noted puffiness of the infant’s hands and
feet.

When the infant was four weeks of age, the
family physician made an examination because of
the symptoms noted above, and made a tentative
diagnosis of milk allergy. She was then placed on
a soybean formula, but when it produced no ap-
preciable change in her symptoms, she was re-
ferred to us for evaluation.

She was first seen in the Outpatient Depart-
ment of Park Hospital, Mason City, on July 20,
1961. Her weight at that time was 8 lbs. 8 oz., and
on physical examination the only significant find-
ing in addition to moderate abdominal distention
was bilateral catarrhal otitis media. Her diet was
changed from a soybean to a meat-base formula,
and she was given an oral mixture of penicillin
and triple sulfa suspension, and a preparation of
atropine and phenobarbital.

Forty-eight hours later, she returned and was
admitted to the hospital because, during the in-
terval, she had developed marked abdominal dis-
tention and increased vomiting. Careful question-
ing revealed that the mother had misunderstood
the directions regarding the atropine-phenobarbi-
tal preparation and had been giving the infant a
double dose in an effort to control her irritability.
At that time, a diagnosis of atropine intoxication
was made.

X-ray films of the abdomen showed abnormal
distention of the small and the large bowel, with-
out fluid levels or other evidence of obstruction,
and those findings were thought to confirm the
diagnosis of atropinism.

Laboratory studies showed no abnormalities in
urinalysis or peripheral blood, and a sweat test
for cystic fibrosis was reported negative.

The infant was treated with warm stupes, a
rectal tube and methylpolysiloxane.* On that
regimen, the abdominal distention cleared dra-

* Mylicon®, The Stuart Co., Pasadena, California.

285

286

Journal of Iowa Medical Society

May, 1962

matically, and the child was discharged after a
five-day hospital stay.

She returned to the Outpatient Department on
August 23, 1961. She had been relatively asympto-
matic in the meantime, but had gained no weight.
At that time, her hemoglobin was found to be
9 Gm. per cent, and she was found to have a dif-
fusely audible systolic murmur, which was thought
possibly to be hemic in origin. An oral iron prep-
aration was added to the regimen of meat formula
and antispasmodics.

The infant's final admission occurred on Sep-
tember 14, 1961, when her chief complaints were
generalized puffiness and a tendency to bleed
easily. The mother stated that the mild puffiness
of the hands and feet noted earlier had markedly
increased during the previous two weeks, and
that during the same period swelling of the face
had developed. Five days before admission, a
blood count had been taken, and the heel puncture
had not stopped oozing. The baby had scratched
herself behind the ear, and this wound also had
continued to bleed. Otherwise, the history was
essentially the same — that is, some irritability and
occasional vomiting, with slow weight gain, but
normal stools.

On physical examination, the baby weighed 9
lbs. 1 oz. Her temperature was 99.0°F., rectally.
She was noted to be grossly edematous, the swell-
ing being evenly distributed over her face, trunk
and extremities. Otherwise, except for moderate
abdominal distention and bleeding from the heel
and from behind the right ear, there were no
positive physical findings.

Laboratory work showed the hemoglobin to be
10.4 Gm. per cent, the hematocrit 33 per cent, and
the white blood cell count 18,500/cu.mm., with a
differential of 1 eosinophil, 6 stabs, 42 polymorpho-
nuclear leukocytes, 49 lymphocytes and 2 mono-
cytes. The platelets numbered 490,000. The bleed-
ing time was 2 min. 45 sec., and the coagulation
time was 5 min. 15 sec. A urinalysis was negative.
The nonprotein nitrogen was 27.6 mg. The total
protein was 3.05, the albumin 1.52 and the globulin
1.53, resulting in an albumin/globulin ratio of 1:1.
An x-ray of the chest was reported as normal, and
a flat plate of the abdomen was described as
showing mild gaseous distention of the small and
the large bowel — again not typical of intestinal
obstruction.

Griffin’s article was brought to our attention
on the day the infant was admitted to the hospital,
but before diagnostic studies could be carried out,
she went into sudden collapse and expired.

At postmortem examination, except for general-
ized edema and evidence of considerable oozing
from venipuncture sites, the significant findings
were limited to the colon: “The ascending and
transverse colon are markedly dilated and have a
diameter up to 4 cm. There is a sudden reduction
in the size of the colon at the splenic flexure, and
the rest of the large intestine is moderately con-

tracted.” Microscopically, the pathologist reported,
“ganglion cells are present in the intermuscular
plexus in the dilated proximal portions of the
colon. In the contracted distal part of the colon,
ganglion cells are absent.”

DISCUSSION

Our experience agrees with that of Gross2 in
that although constipation is the rule in infants
with congenital megacolon, diarrhea may appear
at times if fluid intestinal matter is passed around
inert fecal masses. In the patient presented here,
the number of character of the stools did not ap-
pear abnormal at any time. In general, severe
abdominal distention is to be expected in Hirsch-
sprung’s disease. In our patient, it developed once
but probably was misinterpreted as having re-
sulted from atropine intoxication.

Griffin has postulated that the hypoproteinemia
and edema noted in his paptient were the result of
malabsorption during episodes of diarrhea. A
careful review of the history in the present case,
however, fails to bring out any significant period
when the stools were considered loose. Moreover,
the nurses’ notes contain no mention of other than
soft, formed, yellow or brown stools during either
of the infant’s two hospitalizations. We also were
able to exclude the possibility of massive pro-
teinuria as the cause of the infant’s low serum
proteins and edema.

Typical symptoms of constipation and abdominal
distention were not present to such a degree as
to make the diagnosis of Hirschsprung’s disease
apparent. However, knowledge of Griffin’s patient
and of the association of hypoproteinemia and
edema with congenital megacolon led to a correct
diagnosis — unfortunately too late to help the
infant.

SUMMARY

A case has been presented in which an infant
expired at the age of three months with massive
edema and hypoproteinemia. Although her brief
lifetime had been marked by episodes of irritabil-
ity, vomiting and failure to thrive, it had been
significantly lacking in constipation, diarrhea or
abdominal distention.

It is suggested that congenital megacolon be
added for consideration in the differential diag-
nosis of massive edema and hypoproteinemia in
early infancy.

ACKNOWLEDGEMENTS

I should like to thank Dr. D. L. Bray, of Algona,
and Dr. G. J. Sartor, of Mason City, for permis-
sion to report this case, and Dr. Paul H. Potter, of
Mason City, for the autopsy material.

REFERENCES

1. Griffin, J. W.: Congenital megacolon (Hirschsprung’s

disease) associated with hypoproteinemia and edema: case
report. J. Pediatrics, 59:394-396, (Sept.) 1961.

2. Gross, R. E.: The Surgery of Infancy and Childhood:
Its Principles and Techniques. Philadelphia, W. B. Saunders
Co., 1953, p. 334.

Diagnosis and Treatment of
Brain -Damaged Children

At the Child Development Clinic, S.U.I. Department of Pediatrics

ROBERT B. KUGEL, M.D., and
THERON ALEXANDER, Ph.D.

Iowa City

Dr. Kugel: Brain damage is a term which in the
past decade has been used frequently by a variety
of people. Like many of the terms which we use,
it is not always precisely applied, and sometimes it
does not convey a great deal of meaning. The term
can certainly imply many different etiologies. In
no sense do I think it ought to be construed as
meaning any particular entity. Thus, under the
heading of brain damage, we might be discussing a
child who had a disorder of his brain as the result
of some prenatal infection, e.g., rubella. On the
other hand, brain damage might apply to the child
who had a subdural hematoma occurring after
birth, and who had some disorder of the brain fol-
lowing that particular occurrence.

Another concept which I think is important in
understanding this syndrome or condition would
be a realization that not all children designated as
having brain damage are necessarily mentally re-
tarded. Mental retardation is an equally difficult
term to define, and efforts to avoid confusion by
speaking only in terms of a child’s particular in-
tellectual ability have not always been fruitful.
We find that certainly there are children with
brain damage who have intellectual levels ranging
from severe mental retardation to normal and even
above normal intelligence. We are aware, then,
that there is a continuum of conditions which may
well involve intellectual functioning.

Since intelligence is inexorably intertwined with
the personality development of the individual and
his behavioral manifestations, we have to try to
understand what kinds of behavioral manifesta-
tions one may anticipate finding in a particular
child, and how these then are related to his par-
ticular type of problem. Some of these are extra-

The authors, a pediatrician and a psychologist at the
Clinic, made this presentation in Iowa City on February 22,
1961, during the Annual Refresher Course jointly sponsored
by the S.U.I. College of Medicine and the Iowa Chapter of
the American Academy of General Practice.

ordinarily subtle. A little later, I shall present a
case to you which I think illustrates very well
some of the subtleties of the problem that we are
talking about here today.

NEED FOR AN INTERDISCIPLINARY APPROACH

Most of us in medicine, having a strong biological
orientation, have for some time found it difficult to
understand that there can be manifestations of
function in the absence of clearly defined structure.
For many years, of course, people have been con-
cerned about the function of certain anatomical
structures. For instance, we have long been con-
cerned with the controversy about the function of
the thymus gland. I think that mcst of us would
find it difficult to believe that the thymus gland
does not have any function. That we are unable to
describe its function accurately is all too true.
Similarly, when we come to the brain, we are all
well aware of the relationship between structure
and function in certain portions in the area of the
motor cortex. For example, we comprehend the re-
lationship between structure and function in cer-
tain cells, and we clearly understand the signifi-
cance of certain pathologic lesions.

When it comes to behavior, however, we enter
into the realm of things that are somewhat less
definite and sometimes even border upon the mys-
terious. We are less able to state a clear one-to-one
relationship. A few years ago, when prefrontal
lobotomies were used for the treatment of certain
psychotic episodes, people were disconcerted to
observe that sometimes one could essentially dis-
lodge a whole portion of the brain with little dis-
cernible effect. The prefrontal lobotomies were by
no means universally successful, and there has
been an increasing realization that the frontal
lobes do have certain functions, though it is still
not completely clear what they are.

A structure as complex as the brain often re-
quires, in today’s world, the aid of many people if
we are to understand its functions. Historically, in
medicine, we have been under the strong influence
of the Germanic school of pathology. From the
clear discussions of Virchow,1 we came to un-
derstand the relationships between certain his-
tologic lesions and their pathologic effects. We

287

288

Journal of Iowa Medical Society

May, 1962

are greatly in debt, of course, to this cause-and-
effect type of thinking. With the development of
biochemistry and psychology, in the twentieth cen-
tury, we find that there are many things which one
cannot demonstrate on dead tissue, but which we
are very certain exist, nevertheless, in the living
individual. An example would be convulsions.
Anyone can see a grand mal seizure and know that
it is abnormal, and we can get an electroencepha-
lographic tracing and know that it is abnormal, but
if the patient were to die and we were to examine
his brain, we probably would be hard pressed to
demonstrate any lesion whatsoever in his brain,
even with the most meticulous of histologic stain-
ing technics. We therefore must say that at the
cellular level, we are often unable to demonstrate
what is obviously a pathologic effect in the living
individual.

Returning to our subject for today, this sort of
phenomenon is abundantly clear as we look at the
problems of children who have a variety of be-
havioral manifestations. I should therefore like to
try to explain something of the concept of how in-
terrelated the psychological functioning of the in-
dividual is with his neurologic condition. Dr. Alex-
ander will elaborate on some of the psychological
manifestations of these conditions, and then we
shall try to demonstrate all of this further in a pa-
tient.

Dr. Alexander: Just as there are wide variations
in the degrees of occurrence of encephalopathy,
there are also wide variations in the degrees of im-
pairment of the individual by an unfavorable en-
vironment. We are constantly making an effort to
relate medical histories to the functioning of the
individual in his efforts to cope with the world
about him. Where there is considerable evidence
of an encephalopathy, both from the standpoint
of medical history and from the findings on ex-
amination, one usually, in addition, can see be-
havioral impairment.

If the encephalopathy develops at birth or during
the prenatal period, it is likely that the develop-
mental acquisitions of the child will be delayed.
There is usually delay in motor behavior — in
sitting, in walking, and in the manipulation and
control of objects. The child has difficulty in ac-
quiring self-care skills such as managing his cloth-
ing and feeding himself. It is also likely that there
is some impairment in social responsiveness, in
communication, and in using verbal symbols.

The significance or meaning of stimuli about him
and those that come from other people and from
interpersonal interactions presents difficulties to
him. As the child grows, the meanings of different
objects and the learning of appropriate responses
to them continue to be an area of difficulty. For
example, distinguishing between objects that can
be explored and those which must be left alone is
difficult for him. Efficient utilization of energy
available to him presents further problems. Some
stimuli have little significance for him, and he
shows a tendency to go from one stimulus to

another without devoting sufficient time to each.
Thus, the child fails to respond efficiently, because
he does not occupy himself with any one stimulus
for a sufficient length of time. Usually, parental
restraint becomes an important factor, and the
child is unhappy much of the time because of his
lack of internal control. Accordingly, environ-
mental factors begin to play an important part, and
the child’s fearfulness increases as a result of his
inability to control his body and to understand and
to cope with the world about him. Associated with
the elements of anxiety and fearfulness are self-
comforting mechanisms. Frequently these mecha-
nisms are of a somatic nature — rocking the body,
banging the head, etc.

The development just described is that which
is seen frequently in the child with a diagnosis of
extensive encephalopathy, but there are, of course,
milder manifestations. The child with a diagnosis
of only mild encephalopathy will show some im-
pairment, too. It often is difficult for him to manage
a fine motor task such as tying his shoes or color-
ing within the lines in a coloring book. Because of
some inadequacies both in his capacity for under-
standing and in his use of his body in relation to
his environment, a child with even mild enceph-
alopathy may also develop anxiety and fearfulness.
These psychological symptoms further impair his
general effectiveness.

Since the educational system requires com-
petency in many areas, not only in motor tasks and
in procedures involving abstract thought or mem-
ory, but also in social control and effectiveness,
these neurologically and psychologically impaired
children have problems in meeting many of the
school requirements. Frequently, the complaints
that parents have about such a child relate to his
troubles at school. It is important, however, that
the child’s difficulties should not necessarily be
regarded as directly related to skill acquisition in
school subjects. Rather, his total problem lies in
reconciling his emotional well-being and his phys-
iologic impairment. It is obvious, too, that the
child with impairment will also need some modifi-
cation as far as expectations for his development
are concerned. Therefore, flexibility within the
family and in the educational system is necessary
for all children with deviations from normal de-
velopment.

Of course, there are children who have minimal
signs of a pathologic nature. These minimal signs
are sometimes characterized only by abnormalities
in the electroencephalogram. The complaints which
may bring such a child to the clinic are deficiencies
in mastering school subjects, disobedience, fear-
fulness, or a lack of attentiveness. In such children,
it is my opinion that psychological factors out-
weigh the minimal physiologic ones, and that such
children, if not in unfavorable psychological cir-
cumstances, can manage to meet the requirements
of society in a satisfactory manner.

In dealing with the total problem of brain dis-
orders in children, there are two important con-

Vol. LII, No. 5

Journal of Iowa Medical Society

289

siderations. First, through scientific research every-
thing must be done to prevent the occurrence of
such problems. Second, if the child has a brain
disorder, everything possible should be done to
provide him with a favorable psychological en-
vironment.

We, who see patients in the critical or early
phase of life, are greatly impressed by the fact that
many of them come to our clinic with psychological
factors that oftentimes impair their general effec-
tiveness as much as do their physiologic ab-
normalities. With the physiologic impairment
alone, many of the children seen in our clinic can
manage quite well, but if unfavorable environ-
mental factors are present — divorce, parental re-
jection, lack of parental understanding and societal
rejection — these added difficulties greatly com-
pound their problems. Then, children are con-
siderably troubled and cannot conform to society’s
demands. Consequently, as children who have
brain disorders are seen, it is important that efforts
be made to obtain as favorable as possible an en-
vironment for them, and that parental discord and
family conflicts be dealt with from a psychological
and social viewpoint so that the child will not be
additionally impaired.

CASE STUDY

Dr. Kugel: The history of Susan will illustrate
some of these factors we have been talking about.
This girl is nine years old, and by and large, she
is a relatively healthy youngster. When her mother
first came, in November, 1960, her concern was
about the child’s school adjustment. In school,
things had not been going well. There had been
the matter of this child’s frequently having temper
outbursts. She had not been achieving as the
school people thought she could, and had not been
displaying the type of behavior expected of a
fourth-grade child.

Her mother had been concerned about her
daughter’s behavior for some time, but her concern
reached a point of action, as it often does, when a
complaint came from the school that Susan was
having difficulty in meeting certain norms. As one
talked with the mother, it became apparent that
she had been concerned about this girl for several
years. The way in which she described the young-
ster’s behavior was interesting. She described it
as “alternately friendly and ruthless.” The word
ruthless was her own and I think it is significant
that she used it to connote a severity of behavioral
manifestation.

The mother is an older woman, being 54 years
of age, and perhaps her age is a part of her daugh-
ter’s problem. She has a son 34 years of age and
another daughter who is 22 years of age, which is
a wide range in ages. The son has severe cerebral
palsy and mental retardation, and is now in a
custodial home. The daughter has married and is
living in California. Susan is a child who had not
been planned for. Both parents were most upset
about this late pregnancy. They wonder whether

they have over-compensated for their earlier feel-
ings of rejection by, at times, being very indulgent
to this little girl. They have provided her with
many things that neither parent had as a child.
They have given her many clothes, and Susan is
always very well dressed. She has all of the toys
and other things that a youngster of her age wants
— a great abundance of them.

In her early history, we learned, the child had
had episodes of chickenpox and measles occurring
simultaneously. This phenomenon is not rare, but
when we see it, there is often reason to be con-
cerned. The child had been stuporous at that time,
and had fever ranging to 105°F. for several days.

We lack sufficient evidence to state conclusively
that this child did have an encephalitis, but the
symptoms, as we reconstruct them, are highly sug-
gestive of it. Thus, one might make a presumptive
diagnosis that the child had had an encephalitis as-
sociated with these other disorders at the age of
five years. Actually, the mother dates her daugh-
ter's problem from that time, as far as her main
behavioral manifestations are concerned. Although
it was true that, for instance, the problems of the
child’s being accepted into her family and being
overly indulged antedated the illness, they came
out in bolder relief following her very serious sick-
ness.

In addition, this youngster’s father has had some
chronic heart disorder, and recently has tended to
withdraw from the family circle. He has been
highly critical of the way in which the child has
been managed, from a behavioral point of view,
but has been unable to take an active role in al-
tering the pattern.

As far as the neurologic appraisal of this child is
concerned, she is essentially intact, and all of her
responses are clear, precise and certainly well
within the normal range except for some minor
motor deficit. We have been interested here in
getting a better understanding of the usefulness of
the electroencephalograph as an indicator of ab-
normal cerebral physiology. Using the EEG in a
closely controlled fashion, we find that a long
tracing obtained over a period of about an hour,
including a sleep record, will often enable us to
find aberrations that one is unable to discern in
shorter records. In this instance we found some
disorders in the electroencephalographic tracing,
and we have added those findings to our other evi-
dence to suggest that the child has diffuse enceph-
alopathy of unknown etiology.

Here we have, then, an example of a child who
has been given less than adequate psychological
nurture, and in addition has some degree of phys-
iologic impairment. Behaviorally, we have a child
who is not functioning up to the expected norms
for her age. The combination of these two ab-
normal factors, the psychological and the neuro-
logic, is an especially pernicious one.

This child is an example of what both Dr. Alex-
ander and I have been discussing. It is interesting
to note that the children in whom one or the

290

Journal of Iowa Medical Society

May, 1962

other of these manifestations seems to be absent,
have a better total life adjustment. For example,
one certainly finds children with various types of
brain disorder who have excellent psychological
adjustments. On the other hand, we see children
who have been reared in most unfortunate types of
environment who are able to survive their handi-
caps in a relatively unimpaired fashion.

A psychiatrist who has been interested in this
problem, Lauretta Bender,2 has pointed out after
years of viewing the large numbers of children
raised in poor circumstances in New York City,
that it is not surprising to find children with psy-
chiatric disorders but only surprising that there
are not more of them. Bender postulates that when
we have the combination of some degree of en-
cephalopathy along with inadequate psychological
climate, we are more apt to have a devastating end
product than when either factor is present alone.

DISCUSSION OF PSYCHOLOGICAL FINDINGS

I would like to ask Dr. Alexander to elaborate
on some of the psychological findings as they relate
to this specific case.

Dr. Alexander: Not very long ago, we had two
pediatricians from the British Isles working with
us in the Child Development Clinic, and when they
first came, they expressed the opinion that Amer-
ican physicians seemed to rely upon the laboratory
more than they probably should. I think that their
views changed after they had been here a while,
but they were right, perhaps, in thinking that
sometimes there is a tendency for all of us to de-
pend upon our measurements and other mechanical
technics too much and upon reasoning too little.

In studying this child, it was possible for us to
obtain a number of psychological test scores, but
they must be interpreted in a context of other
information and background material.3 The infor-
mation from some tests does not contribute very
much. Susan is functioning in the low-average
range of ability on the Wechsler Intelligence Scale
for Children ,4 The Vineland Social Maturity Scale 5
is a technic for indicating the parent’s view of de-
velopment. The child’s parent is asked certain
questions about the child’s accomplishments — how
the child can manage an allowance, how well the
child can take care of household tasks, and how
responsible the child is in fulfilling parents’ re-
quirements. By these two yardsticks or tests, this
particular child is in the average range. However,
we do know that she is having difficulty. The
mother was upset about the child’s behavior, as
was the school. So, despite the fact that these test
scores indicate that the child is all right, we know
otherwise.

There are other kinds of psychological technics
of course. For example, there are technics to study
the ability to reason and to measure the complexity
of response.6 Our research has indicated that one
can grade the subject’s ability to assign meaning
to a stimulus and to perceive cause-and-effect re-
lationships.7- 8 In such a test, the child whom you

have seen this morning is seen to be impaired and
inadequate. We are constantly looking to find new
ways of understanding such a difficulty as this
child has. As Dr. Kugel has pointed out to you, if
the child has some anxiety about her own capacity
and about her means of coping with the world and
if, in addition, there is parental discord and anxiety
for the child about her place in her family, the
problem is compounded.

It should be emphasized once more that most of
the problems that we see are those of children who
are either mild or borderline cases — ones who are
not doing very well and who, on the other hand,
are not doing very badly. Usually, their difficulties
are both physiologic and psychological.

Dr. Kugel: In the management of such cases, we
realize the need for using the abilities and re-
sources of many people. All of us prefer to deal
with the relatively straight-forward medical situ-
ations. We feel that we are on firm ground — or, I
know I do — when I see a child who has a tempera-
ture of 104°F. and learn that there are streptococci
present. We administer penicillin and dispatch the
problem with little residual concern, in most in-
stances. This we like to do, and it is the kind of
thing that is totally within the confines of our un-
derstanding and abilities as physicians. Unfor-
tunately, however, either as medicine has broad-
ened or as we have become aware of the complex-
ities of things, it is often impossible for us to handle
all problems unaided. Such is the case in this in-
stance.

We attempted to approach this child’s problems
from the standpoint of three things: (1) medica-
tion to help in the control of her behavior, (2) in-
terpretation of the problem to the school, and (3)
counseling with her mother about how she might
help to be more constructive with Susan.

MEDICATION

I should like to deviate from the discussion of
this girl and to talk more generally about the kinds
of problems that are presented to us. What about
medication? In the past quarter century, we have
seen many new drugs become part of our arma-
mentarium, and some of them have greatly facili-
tated patient care. First came the antibiotics, and a
little later came the steroids. We are now attempt-
ing to grapple with some of the drugs that have
some effect on the brain and its functions. We un-
derstand some of the analeptic drugs somewhat
better than we did at first. Yet we have had diffi-
culty in evaluating them because our cases are
often elusive — caused by many different factors —
and our tools for assessing and appraising the re-
sults are not always definite. As for the literature,
we are confronted with reports which say that a
drug was given to a patient and that he “felt
better.” It is hard to know whether he felt better
because he had been given a pill, or whether he
felt better because of the action of the pill.

I think we must exercise great caution in the

Vol. LII, No. 5

Journal of Iowa Medical Society

291

whole area of the so-called tranquilizing drugs or
drugs with a sedating of stimulating action. They
must be considered very carefully and assigned
their proper place. I think it doubtful that we shall
find drugs capable of completely replacing some of
the other things that I shall mention. At the mo-
ment, we need to provide management of patients
which integrates the physiologic and psycho-
logical components. One of the comments that
Freud9 made in his latter years was that psycho-
analysis was really useful only insofar as it was a
means of understanding the behavior of the indi-
vidual. He went on to say that the time might well
come when we could influence behavior more di-
rectly as a result of the use of drugs. He wrote in
the mid 1920’s entirely before the era of the
tranquilizing drugs. Freud began as a student of
neurology and had that field as his first interest. He
was much concerned about these problems of the
interrelationship of structure and function.

As we learn to control certain types of convul-
sions, we should not give up hope of controlling
other manifestations of disorder which, although
they are elusive at the moment, may not always
be so. We have had Susan, for example, on Dean-
er®, a drug manufactured by Riker. It is one of a
group of amphetamines that seem to have some
promise when used in rather large doses for this
particular kind of condition. These drugs seem to
reduce some of the extraneous and upsetting be-
havior which Dr. Alexander described.

It is certainly important in this particular case,
as it is in so many others, for us to enable both the
parents and the teachers to assess the child’s abil-
ities and disabilities, and to achieve degrees of
flexibility which they have hitherto lacked in deal-
ing with these children. We have endeavored to
work with Susan’s mother to help her understand
what she was doing with this child, and she has
made some progress in this regard. I think that
otherwise we would not have seen the changes
which have occurred in this girl.

There are things that yet need to be done in this
case, as there almost always are. Just as important
as what we did with the mother, was our attempt
to work with the school. All of us today are con-
cerned with the children’s performance in school.
We are told that we do not compare with the Rus-
sians in our accomplishments, and that charge is
having its effect upon our schools. Educators are
attempting to clamp down and to have children
conform to higher standards. Whereas this may be
salutary for the population as a whole, it creates
a problem for the child who is on the fringe of
adequacy or for the child who is having difficulty
in meeting the norm. I think it essential that we
understand that there are individuals who cannot
meet any set standard. Thus, we must develop
latitude in our educational system, at every level,
for coping with the child who has some type of
deviant quality. This tolerance is difficult to
achieve, but I think it is an important thing, and

certainly as physicians we need to interpret our
feelings and thoughts to the school people who
have so much influence on the child’s life and in
the development of his potential.

If we can weave together the three aspects that
I have mentioned, the outlook for such children
can be very much improved. Susan has a chance,
we feel, to adjust to her world in a more satis-
factory fashion. If the patient were a boy, we
should be inclined to feel that there were strong
antecedents for antisocial behavior. I do not mean
to say that there cannot be problems with girls, but
boys have more chances for getting into trouble. As
far as total maladjustment is concerned, however,
the seeds have already been planted in Susan’s
psychological make-up, and it is up to us to attempt
to alter some of the processes. To conclude my re-
marks, I should like to say once more that in these
children’s problems we have a subtle interweaving
of both physiologic and psychological manifesta-
tions which produce the end-product of disorder.

Dr. Alexander: As has been emphasized, one
cannot expect to see medications at present reliev-
ing intellectual impairment or encephalopathies
to any considerable extent. It is possible that some
drug might enhance the functioning of the brain
and increase the individual’s potential for receiving
stimuli and his capacity for responding to com-
plexities. But whereas a number of drugs have had
such goals and purposes, their effects have been
limited. Our purpose in making use of Deaner®
has been to attempt objectively to measure the
changes that take place.

In studies concerned with the effect of drugs on
behavior there are, of course, many pitfalls. We
have tried to avoid some of them. We are aware
that not all of the factors in these studies may
have been controlled, and that there may very
well have been improvements in the behavior of
these children that are not attributable to the
drug. On the other hand, there may have been im-
provements as a result of medication that we are
unable to measure. In any event, in our present
research study we rely upon four objective psy-
chological measures, in addition to whatever the
parents or others may report to us about the be-
havior of the child.

My only comment at the present would be that
we see general satisfaction among the participants
in the study, and there seem to be improved at-
titudes on the part of the parents toward their
children. Objective data have yet to be analyzed,
and whatever contributions such data make or do
not make, it is clear that the people cooperating
have been pleased to participate in the study. We
believe the usefulness of such drugs will require
extensive evaluative effort before definite con-
clusions are warranted.

TYPES OF CASES TREATED AT S.U.I.

Dr. Alexander and Dr. Kugel: We cannot, of
course, describe the frequency or incidence of

292

Journal of Iowa Medical Society

May, 1962

neurologic deficit in children in our society or
state. We can, however, describe and determine
the types of problems which are brought to the
Child Development Clinic in the Department of
Pediatrics. Theoretically over a period of time our
study should provide information which would
lead closer to a description of incidence in the
general population.10 We are unable to provide
any information as to the total incidence, since we
are certain that many such children are not re-
ferred to University Hospitals. However, in the
Child Development Clinic we have no limiting
factors on the types of neurologic deficit or en-
cephalopathy seen and, therefore, the percentage
of incidence within the sample encountered should
be of some value. We are aware, of course, that
there are influences of sampling over which we
have no control, although in the Child Develop-
ment Clinic patients range over the various social
classes in our society.

In Figure 2 it can be seen that children are re-
ferred to the Child Development Clinic from over
the entire state. The larger number of referrals
comes from the populous areas close to University
Hospitals. It should be noted, however, that all of
the areas of the state are represented. Figure 3
illustrates the occupations and general background
of the people coming to the Child Development
Clinic. While Iowa is overwhelmingly a rural state,
it is to be noted that by far the larger per cent of
patients comes from families depending on income
from industry rather than farming.

Figure 4 contains information about the per-
centage of the patients in the various diagnosic
categories seen in the Child Development Clinic.
The statistical mode occurs at the category of en-

NUMBERS OF PATIENTS

Figure I. Numbers of patients seen in the Child Develop-
ment Clinic.

cephalopathies resulting from trauma or some
physical agent. Most such difficulties are associated
with problems of birth. It also can be seen that
there are many children with encephalopathies
which have resulted from some unknown prenatal
influence. In our study of these children it has
been possible to learn that the difficulty was
present before birth. Many of these disorders are
various types of congenital anomalies. Also, many
children are seen to have neurologic deficit and
encephalopathy, but we are unable to determine
the cause — that is, whether the etiology was pre-
natal or postnatal. Further, when one examines
Figure 4, it is apparent that there are many chil-
dren with behavior disorders whose behavior does
not conform to society’s demands, but who are
found from our study to be free of neurologic
disorder. As far as we can determine, no evidence
of encephalopathy exists. About 5 per cent of the
total number of children referred to the Child De-
velopment Clinic are found to have psychophys-
iologic and psychological difficulties. Almost all
of these cases are diagnosed as having ulcerative
colitis. There are, however, other patients who
have cardiac and dermatologic problems. A few
children are referred to the Child Development
Clinic who, as far as we can determine, appear to
be normal both physiologically and psychologically.
Such children usually have been referred because
the parents have had difficulties and have been
concerned about the effect of family disorder on
the child. And, in some cases, they have believed
the child to be deviant but we have found the
difficulties lying predominantly with the parents.
Such children, at the time of study, display no
significant abnormalities.

The study of children who have neurologic and
psychological disorder is relatively new, and has
not had the emphasis that other areas of disorder
have had. Both knowledge and means of treatment
are as yet inadequate, but the considerable signifi-
cance of these types of problems is increasingly
being recognized. It is likely that great advances
will be made in these important areas within the
next few years.

REFERENCES

1. Virchow, Rudolph: Cellular Pathology as based upon
Physiological Histology. Philadelphia, Lippincott, 1863.

2. Bender, L.: Child Psychiatric Techniques: Diagnostic and
Therapeutic Approach to Normal and Abnormal Development
through Patterned, Expressive, and Group Behavior. Spring-
field, Illinois, Thomas, 1952.

3. Alexander, T. : Mental Subnormality: Illusions and Direc-
tions. Internal. Record Med., 172:80-86, (Feb.) 1959.

4. Wechsler, D.: Wechsler Intelligence Scale for Children.
New York, The Psychological Corporation, 1949

5. Doll, E. A.: Vineland Social Maturity Scale. Minneapolis,
Educational Test Bureau, 1947.

6. Alexander, T.: The Behavioral Complexity Test: A Test
for Use in Research. Iowa City, State University of Iowa,
1961.

7. Alexander. T.: Influence of central nervous system and
behavior disorder upon complexity of response. Amer. Psy-
chologist, 16:351, (July) 1961.

8. Alexander, T., and Kugel, R. B.: A concept of behavioral
complexity: A study of factors of normality, psychopathology,
and culture related to behavior of children. To be published
in Genetic Psychology Monographs, 1961.

9. Freud, S.: Selected Papers on Hysteria and Other Psy-
choneuroses. New York, The Journal of Nervous and Mental
Disease Publishing Co., 1909.

10. Redlich, F. C., and others: Social structure and psy-
chiatric disorders. Am. J. Psychiat., 109:729-734, (Apr.) 1953.

Vol. LII, No. 5

Journal of Iowa Medical Society

293

RESIDENCE OF PATIENTS BY COUNTIES

Figure 2. Distribution in the state of patients seen in the Child Development Clinic for the year 1960-1961:

Out of state 19

Total Iowa 478

Grand Total 497

FATHER'S OCCUPATION

Figure 3. Percentage distribution of patients according to
father's occupation.

MEDICAL AND PSYCHOLOGICAL
DIAGNOSTIC CATEGORIES

Encephalopathies due to-

Percent

Figure 4. The frequency distribution of medical and psycho-
logical diagnostic categories of patients seen in the Child
Development Clinic based in part on the system of classifica-
tion of the American Association on Mental Deficiency.

* Father separated.

The Face of Depression

A. S. NORRIS, M.D.
Iowa City

Most physicians are unaware that depression is
one of the commonest of all illnesses.1 According to
one estimate, 40 per cent of the patients whom
family physicians see have illnesses that are pri-
marily emotional, and depressions constitute a
large share of that group.2 Forty per cent of major
depressions, moreover, resemble one or another
physical disease, and the differential diagnosis may
be quite difficult.3 The depression may also be a
symptom of physical disease.

At best, failure to diagnose a depression may re-
sult in much futile and useless investigation; at
worst, it can be fatal. Suicide is one of the most
frequent causes of death in this country. Over
20,000 people each year take their own lives, and
another 100,000 make the attempt.

PRESENTING SYMPTOMS

The patient is unlikely to tell the doctor that he
is depressed. Often he is unaware of his depression,
or if he recognizes it, he does not acknowledge
it, for he regards such a statement as an admission
of weakness or insanity. Very often, he complains
of a physical symptom, and does not associate it
with his depressed mood. Unfortunately, phy-
sicians also fail to see this relationship in many in-
stances.

The depressed patient commonly presents with:

1. Somatic pains and aches

2. Constipation

3. Fatigue

4. Weight loss

5. Nervousness

6. Insomnia

7. Loss of libido.

His relatives may have urged him to seek med-
ical help because they have noticed a change in
his pattern of behavior. They may complain that
he gets no work done, that he appears withdrawn
and that he prowls around at night. A sudden bout
of alcoholism can be a symptom of depression, or
the patient’s decision to sell his farm, give up his

Dr. Norris, an assistant professor of psychiatry at the S.U.I.
College of Medicine, made this presentation to the Spring
Conference of the Iowa Chapter of the American Academy of
General Practice last June, at Lake Okoboji.

job or, generally, to “give up” in any endeavor
may be significant.

There are many clinical types of depression, but
it is more important for the physician to distin-
guish between the mild and the severe kind than
to pigeonhole them in specific psychiatric classi-
fications. The mild cases are usually amenable to
office therapy, but severely depressed patients are
often suicidal, and office treatment is thus con-
traindicated.

MILD DEPRESSION

A mild depression may manifest itself in many
ways, but the following case will illustrate some of
the commoner ones.

Mrs. Smith, aged 34, describes her symptoms:
“I’m not the same as I used to be. I used to like
people, and I belonged to a lot of clubs. I enjoyed
doing everything. I had lots of pep. I could clean
house, work in the office, cook dinner and be ready
to go out in the evening. But for the past few
weeks I’ve been so tired. I don’t enjoy anything,
and nothing seems to be worth trying. I’ve been a
lot more tense; I have trouble going to sleep at
night.”

Questioning often elicits some precipitating
event such as a change or loss of job, or the un-
fortunate end of a love affair. These patients may
present themselves with any number of symptoms,
and further questioning will reveal others. They
may include complaints of nervousness, the feeling
of being unable to concentrate, a difficulty in re-
membering or a difficulty in thinking. The patient
may complain of being worried all of the time or
of not getting a “kick” out of anything. Often,
there is initial insomnia (difficulty in getting to
sleep), a decreased ability to enjoy eating, and
some weight loss. There may be a decreased in-
terest in sex. Anxiety and tensions are often pres-
ent, and there frequently is a history of recent
environmental stress.

During the interview, the patient appears fairly
normal. He gives his history easily and coherently.
He may appear sad and somewhat tearful, but he
is not profoundly depressed. He can smile and re-
spond appropriately to the physician. Often he
feels better after having had a chance to talk about
the way he feels.

The common symptoms of mild depression are:

1. Fatigue

2. Poor concentration

3. Initial insomnia

4. Loss of interests

294

Vol. LII, No. 5

Journal of Iowa Medical Society

295

5. Anxiety and tension

6. Inability to enjoy things

7. Loss of appetite

8. Some loss of weight.

I repeat, it is extremely important to distinguish
the mild depression from the severe one.

SEVERE DEPRESSION

Mr. McDonald, a 58-year-old man, has been some-
what nervous almost all of his life. In the past three
months, however, he has developed some difficulty
in getting to sleep at night, and he has been waking
up at 4:00 a.m. He is unable to enjoy eating, and
has lost 22 lbs. of weight. He has been worrying
about his business, although he admits that re-
cently he has been making more money than ever
before. The future looks hopeless to him. He ad-
mits that he has thought of suicide. He has had
feelings of worthlessness, and has wondered
whether other people know about all of his past
sins and are talking about him.

In his severe depression, the patient is in ob-
vious difficulty. He has feelings of guilt and makes
statements such as “I am a sinner. It’s all my
fault. I have ruined my life and my family.” He
searches far into his past for things that he has
done wrong, and enlarges their importance out of
all proportion.

The physical symptoms are very important diag-
nostic features of severe depression. The patient
describes terminal as well as initial sleep disturb-
ance. Terminal sleep disturbance, in which the pa-
tient wakes at three, four or five in the morning
and is unable to go back to sleep, is almost path-
ognomonic of severe depression. Other physical
difficulties include poor appetite, dry mouth, blur-
ring of vision, weight loss, constipation, and a
diurnal pattern of energy and mood in which the
patient feels worse in the morning when he has
the whole day ahead of him, but feels increasingly
better as the day progresses, until by evening he
may feel almost normal and can, for example, en-
joy TV programs. Most suicides occur in the early
hours of the morning.

The severely depressed patient often appears
physically ill. He looks depressed, and he may
show evidence of malnutrition and dehydration.
His speech and movements may be slow. He may
have difficulty in expressing his thoughts. On the
other hand, he may be excessively active and
agitated, plucking at his clothes and pacing the
floor. Agitation is commonest in older patients.

He is unable to shake the depressed mood. He
cannot accept reassurance. He feels no better at
the conclusion of his interview with the doctor,
and says as he is leaving, “Nothing can help. It’s
all my fault, and I’ve got it coming to me.”

The characteristic signs of severe depression are:

1. Initial and terminal insomnia

2. Loss of appetite

3. Pronounced weight loss

4. Agitation

5. Retardation of speech and movements

6. Pronounced depression of mood

7. Depressed expression

8. Delusions

9. Constipation.

The above symptoms certainly indicate the pres-
ence of depression, but it must be remembered that
depression can itself be a symptom of many things,
including a physical illness. The diagnosis of de-
pression cannot be made with confidence until
physical diseases — particularly chronic ones such
as anemia or carcinoma — have been ruled out.

INTERVIEWING

Seldom will the above histories be recited spon-
taneously by the patient. They usually require
careful observation and skilled questioning. Most
patients fear the diagnosis of a mental or emotional
illness, and become extremely defensive if the
questioning is handled in a headlong fashion.

It is much easier to begin questioning the patient
about his physical difficulties, for in that area he
will have no idea of the implications of his an-
swers. Thus, it is fairly simple to elicit a significant
pattern of constipation, terminal sleep disturbance,
weight loss and a diurnal pattern of energy. This
constellation almost always indicates depression,
and that much can be obtained without the pa-
tient’s becoming alarmed.

If the patients fails to volunteer more, we must
follow the lead to confirm our suspicions. It is
better to probe gently and gradually, and to ap-
proach the more difficult areas with caution. For
example, one might proceed in this order: (1) Do
you have difficulty concentrating? (2) Do you en-
joy your work? (3) How does the future look to
you? (4) How do you feel about yourself? (5)
How do other people feel about you? (6) Have
you ever thought that you might be better off
dead? (7) Have you thought of suicide? (8) How
would you do it? (9) Have you tried it?

The last few of these questions are ones that
physicians are often reticent about asking, for
fear of offending the patient. But if one follows
the above pattern, gradually leading into the
crucial questions, he seldom gets a negative an-
swer, provided that the responses to the prelimi-
nary questions have been affirmative.

The history of previous depression in the pa-
tient, and a family history of depression are help-
ful in the diagnosis. One must ask whether the pa-
tient has had any experience in the recent past
that might be responsible for his feeling of de-
pression— events such as the loss of a loved one,
failure in business, recent illness, surgery or child-
birth. Depression often follows such situations.

When the patient is too defensive and gives neg-
ative answers, and when the doctor is not yet satis-
fied with the diagnosis, the family members should
be questioned. The close relatives’ observations
of the patient can be diagnostic in themselves.

296

Journal of Iowa Medical Society

May, 1962

DIFFERENTIAL DIAGNOSIS

In addition to eliminating possible physical con-
tributions to the patient’s depression, it is also
important to differentiate a clinical depression
from other emotional and mental states.

Normal grief reaction. Depression, of course, is
normal following the loss of a loved one or some
other tragic event. A normal grief reaction, how-
ever, does not include delusions, excessive self-
incrimination, excessive weight loss or sleep dis-
turbances. Moreover, it should terminate in about
six weeks.

Emotionally unstable personality (hysterical
psychopath). The patient with this type of diffi-
culty is the hardest to differentiate from the true
depressive. He may threaten suicide in a very
dramatic way. He often has a history of several
suicide attempts, but somehow he has managed
not to injure himself seriously. More often than
not, the patient is a young man or woman, and
almost always it is quite clear that the near-suicide
has been undertaken in an attempt to manipulate
the environment in some way. Commonly, the
patient’s wishes have been frustrated. The boy has
been denied use of the family car; the girl has been
jilted by her boy friend. Often the patient has
slashed his wrist with a razor, and examination
will show “intention” scars where previous at-
tempts have been made. Barbiturates and aspirin
are also common, but seldom in fatal doses. Al-
though such attempts are mere gestures, and
suicide is seldom truly intended, death can occur
through mismanagement or unforeseen circum-
stances, or a true depression can develop in a per-
son who has made such abortive attempts. Con-
sequently, rather than disregarding them, the
physician must evaluate these people individually.

Schizophrenia. The schizophrenic patient may
be quite depressed, and indeed the symptoms of
depression may be the first obvious ones. Yet
treatment for depression in these cases, although
they will relieve the depression, fail to touch the
central schizophrenic pathology. These patients
are much less predictable than are those with the
usual depressions, and they should be put under
the care of a specialist. Besides depression, one
will find looseness in the patient’s train of thought,
and often will see inappropriate emotional re-
ponses— laughter at a time when laughter is not
indicated, or tears when there is nothing to pro-
voke them. These symptoms are called, respec-
tively, “looseness of associations” and “inap-
propriate affect.”

DANGER SIGNALS

Certain symptoms and signs usually indicate
that a serious depression and a suicidal tendency
are present. It should be added that homicide, not
infrequently, is committed by a depressed indi-
vidual. He feels that the whole world is hopeless —
for example, that atomic war is inevitable — and
that he will do his family a favor by taking them
them with him when he goes.

A deep mood of depression. This can be felt by
the examiner more easily than it can ever be ex-
plained. The patient will express a feeling that the
future is hopeless, that there is no escape and
that there is no possibility of help.

Agitation. This is more dangerous than retarda-
tion of speech and movements, for there is energy
present. Depressions are accompanied by agita-
tion more often in older people than in younger
ones, and correspondingly, we find that the older
the depressed patient is, the more likely he is to
commit suicide.

Severe hypochondriasis. When the patient’s at-
tention is fixed upon his symptoms, when he feels
that he has a hopeless condition such as carcinoma
and when his somatic symptoms have a bizarre
quality — then he is in danger.

Open talk of suicide. This will occur in a calm,
determined way, very much unlike the dramatic
performance of the hysterical psychopath.

Severe insomnia. The patient is getting very
little sleep. Insomnia is terminal as well as initial,
and the patient is very much concerned about it.

Severe weight loss. Losses of from 10 to 50 lbs.
over a few weeks or months are a bad sign.

Self -deprecatory ideas. These include ideas of
sin and the need for punishment.

History of previous serious suicide attempts.

Dehisions and hallucinations. These are usually
self -deprecatory and sometimes are paranoid.
Somatic symptoms may be delusional. For ex-
ample, the patient may be convinced that he has
a hole in his stomach.

When the patient presents any of the above
symptoms, or if he develops them during treat-
ment, it is time for the physician to tell the pa-
tient’s family of the danger, and to get him into
a protected environment where he can be watched
and where he can receive specialized help.

Observing these points will enable the doctor to
prevent most suicides. However, there will be pa-
tients who succeed in taking their own lives, de-
spite all of the physician’s precautions. They will
present none of the characteristic danger signs,
they will give no warning, but yet will commit
suicide. We simply cannot predict the behavior of
all of these patients. We can only do our best.

SUMMARY

Awareness of the likelihood and recognition of
the presence of depression can result in early
diagnosis. Identifying these cases promptly can
save much fruitless investigation and treatment,
relieve a great deal of suffering on the part of the
patient, and very often save his life.

REFERENCES

1. Sloane, R. B.: Depression: diagnosis and clinical fea-
tures. J. Neuropsychiat., 2:S11-S14, (Suppl. No. 1, Feb.)
1961.

2. Sheperd, M., Fisher, M., Stein, L., and Kessel, W. I. N. :
Psychiatric morbidity in urban group practice. Proc. Roy.
Soc. Med., 52:269-274, (Apr.) 1959.

3. Lewis, A. J. : Melancholia: clinical survey of depressive
states. J. Ment. Sc., 80:277-378, (Apr.) 1934.

State University of Iowa
College of Medicine

Clinical Pathologic Conference

SUMMARY OF CLINICAL FINDINGS

An 85-year-old man was admitted to the Univei'-
sity Hospitals for the second time during the night
of October 15, 1961, complaining of sharp right-
upper-quadrant and epigastric pain of 18 hours’
duration. In 1950, the patient had undergone cho-
lecystostomy at another hospital, with removal of
multiple stones. The diagnosis had been acute
cholecystitis and cholelithiasis. In 1952, he was first
admitted to the University Hospitals because of
right-upper-quadrant pain and mild jaundice. A
blood urea nitrogen of 41 mg. per cent prompted
a urologic investigation. Liver function studies at
that time suggested low-grade obstructive jaun-
dice. Diagnoses of congenital right hydronephrosis
and double left renal pelvis were established. Af-
ter a few days of hospitalization, the abdominal
pain, jaundice and azotemia subsided, and the pa-
tient was discharged with no further treatment.
He apparently had no further difficulties until
the episode that occasioned his second and last
admission to the University Hospitals.

On admission, physical examination revealed a
well-nourished man with a blood pressure of
144/88 mm. Hg, a pulse of 80 and a temperature
of 100. 8°F. He appeared to be younger than his
stated age. There was a suggestion of jaundice.
Examination of the chest showed emphysema. On
abdominal examination, tenderness was noted in
the right upper quadrant and epigastrium. There
was no rebound tenderness. Rectal examination
was negative. The hemoglobin was 12 Gm. per
cent, and the white blood cell count was 11,700/cu.
mm. Urinalysis was negative, and the specific
gravity of the urine was 1.018. Chest films showed
emphysema and pulmonary fibrosis. The blood
urea nitrogen was 19 mg. per cent, and the creati-
nine was 1.0 mg. per cent. The total bilirubin was
3.7 mg. per cent, with a direct fraction of 1.9 mg.
per cent. A few hours after admission, his fever
spiked to 103. 7°F., but during the rest of his hos-
pital course, his temperature remained between
99° and 102°F.

On October 16, the day following his admission,
he began to vomit frequently. A nasogastric tube
was passed, but he repeatedly removed it. The

abdomen was noted to be less tender than it had
been on the evening of his admission. Intravenous
pyelograms revealed no function bilaterally. He
was given appropriate intravenous fluids to meet
his daily needs and losses.

On October 17, there was further subsidence of
the abdominal pain. The urine output was record-
ed as 250 ml. for the previous 24 hours, in spite of
a normal blood pressure and the administration of
the appropriate kinds and volumes of intravenous
fluids. The serum electrolytes were: COo 16.7

mEq,/L., sodium 131 mEq./L., potassium 4.5
mEq./L. and chloride 103 mEq./L. Rales were
heard at the right lung base. Bowel sounds were
hypoactive. The serum amylase was 600 units.
Chest x-ray films were as before. Abdominal x-ray
films showed a pattern consistent with mild ileus;
there was no free intraperitoneal air. Tetracycline,
atropine and vitamin K medications were begun.

On October 18, the patient was tachypneic,
oliguric (150 ml. during the preceding 24 hours),
and dehydrated. There was generalized abdominal
tenderness— a definite change from the previous
day. Bowel sounds were absent. A serum amylase
was 64 units. The white blood cell count was
5,200/cu. mm. The serum electrolytes were C02
16.4 mEq./L., sodium 133 mEq./L., potassium 5.3
mEq./L., chloride 105 mEq./L., blood urea nitro-
gen 75 mg. per cent and creatinine 4.2 mg. per
cent. A paracentesis yielded 5 ml. of cloudy, yel-
lowish fluid. Inflammatory cells with no organisms
were noted on direct smear; the amylase content
was 900 units. Escherichia coli was cultured from
this fluid. The urine output began to rise following
the administration of additional intravenous fluids,
which included low molecular weight dextran.
However, tachypnea persisted. By evening, the
patient was severely dyspneic, with wheezing in
both lungs and bilateral basilar rales. Tracheal
suction was not helpful. There was obvious im-
provement following the application of tourni-
quets to the extremities, nasal 02, and intravenous
aminophyllin and morphine. He was rapidly digi-
talized. The C02 was 21.7 mEq./L. at that time.

On October 19, the patient’s condition remained
grave. Severe tachypnea persisted. There were
signs of consolidation of both lower lung lobes,

297

298

Journal of Iowa Medical Society

May, 1962

but no wheezes or rales were present. A tracheosto-
my was performed, and a Byrd respirator was
used to lessen the respiratory effort. The previous
24-hour urine output was 750 ml., and the specific
gravity was 1.017. The serum electrolytes were:
C02 19.5 mEq./L., sodium 133 mEq./L., potassium
4.6 mEq./L. and chloride 105 mEq./L., with a
blood urea nitrogen of 85 mg. per cent and a
creatinine of 5.3 mg. per cent. The abdominal find-
ings remained unchanged. During the day, he
became hypotensive, and Levophed was started
with a fair response. The patient died on the morn-
ing of October 20, 4V2 days after admission.

SUMMARY OF CLINICAL DISCUSSION

Dr. Joseph A. Buckwalter, Surgery: The case
today will be first discussed by Mr. Butterfield,
who will present the views of the junior student
group.

Mr. Donald G. Butterfield, junior ward clerk:
We are presented with the case of an 85-year-old
man who had a history of cholecystitis and chol-
elithiasis, and transient episodes of right-upper-
quadrant and epigastric pain, obstructive jaundice
and azotemia.

In our differential diagnosis, we included the
following: acute pancreatitis, either idiopathic or
secondary to cholelithiasis and cholecystitis, or
secondary to posterior penetrating duodenal pep-
tic ulcer, or secondary to carcinoma of the biliary
tract; or carcinoma of the head of the pancreas
with cholangitis; or appendicitis with perforation.

The lack of emaciation tends to rule out malig-
nancy. The history is not typical for duodenal
ulcer. Cholelithiasis and cholecystitis are suggest-
ed by the past history of both, by mild jaundice,
and by right-upper-quadrant pain which dimin-
ished with the possible passage of a stone. Acute
pancreatitis is known to be one of the complica-
tions or accompaniments of cholelithiasis. Idio-
pathic acute pancreatitis may also give the symp-
toms.

The epigastric and right-upper-quadrant pain,
tenderness, fever, mild jaundice and leukocytosis
on admission may be explained by the involve-
ment of the biliary tract either by gallstones and
cholecystitis or by acute pancreatitis itself. The
accompanying fever and vomiting may have con-
tributed to the dehydration, thus possibly ex-
plaining the oliguria and the intravenous pyelo-
graphic demonstration of non-functioning kidneys.
The right kidney may already have been non-func-
tional, since hydronephrosis had been demonstrat-
ed in 1952. With the decreased renal function, the
patient was unable to handle the normal waste
products and those of the febrile episodes. Azo-
temia and metabolic acidosis developed, as ex-
emplified by the elevated blood urea nitrogen and
the decreased C02 and sodium levels, with tachyp-
nea.

The localized abdominal tenderness decreased,
possibly with the passage of a stone, but later

the abdominal tenderness was generalized, bowel
sounds were absent and mild ileus suggested peri-
tonitis. The peritonitis may have been a result of
the acute pancreatitis. The high serum amylase
and, later, the amylase in the aspirated peritoneal
fluid are quite suggestive of acute pancreatitis.
Escherichia coli is a common organism in septic
peritonitis caused by penetration or perforation.
The absence of free intraperitoneal air rules
against gut perforation. Gallstones obstructing
the biliary tract can lead to cholangitis, penetra-
tion of the duct and acute pancreatitis. Thus, one
could find a septic peritonitis with amylase-con-
taining peritoneal fluid.

Further complications led to the patient’s rapid
deterioration. The peritonitis probably increased
his dehydration, making hypovolemic shock im-
minent. Dextran administration moderately in-
creased his effective circulatory volume and renal
output, but this increased circulatory load may not
have been beneficial. He had a history of chronic
lung disease (emphysema and pulmonary fibro-
sis), from which we might assume right ventricu-
lar hypertrophy. Acute lung disease suggested by
this man’s dyspnea, rales and consolidation may
have resulted from aspiration, uremic pneumonitis
or hypostatic pneumonia. At any rate, the acute
and chronic lung disease may already have made
the heart function borderline, and with the in-
creased circulatory load decompensation may have
resulted. He responded to therapy for congestive
heart failure, but later went into irreversible
shock (probably bacterial in origin) and died.

Therefore, our diagnostic impression is chole-
cystitis with cholelithiasis and acute pancreatitis.
But one must also consider idiopathic acute pan-
creatitis, perforating or penetrating peptic ulcer,
and acute appendicitis with perforation.

Dr. Buckwalter: Thank you, Mr. Butterfield.
The case will now be discussed by our guest, Dr.
Stuart Welch.

Dr. C. Stuart Welch , professor of surgery, Al-
bany Medical School: Mr. Butterfield has done a
very good job, and I couldn’t do a better one. Al-
though essentially I am more or less in agree-
ment, I’ll go over the protocol in detail to see
whether I can bring out anything that might be
a little different.

An 85-year-old man was admitted to this hos-
pital for the second time during the night of Oc-
tober 15, 1961, complaining of sharp right-upper-
quadrant and epigastric pain of 18 hours’ duration.
He had undergone cholecystostomy in another hos-
pital in 1950, and later he had been admitted
here with mild jaundice and a suggestion of bili-
ary colic. I think at that time we shall have to
assume he had a recurrence of his gallstone colic,
then with an additional common-duct stone. At
the time the cholecystostomy was done he prob-
ably also had had a common-duct stone.

Now, cholecystostomy is of value as an emer-
gency procedure, but it is not the operation of

Vol. LII, No. 5

Journal of Iowa Medical Society

299

choice and is not to be recommended if chole-
cystectomy can be done — because, of course, one
leaves the “quarry” and more stones can form.
In almost all cases in which the gallbladder is left,
stones will reform within two or three years. We
therefore have every reason to think that this
man had recurrent cholecystic disease. Since the
patient’s common duct had never been explored,
we have reason to think that stones had been
present in this common duct for a long time.

It was found that he had a congenital right
hydronephrosis and a double left renal pelvis.
We know that anomalies of the urinary tract pre-
dispose to infection, and one interesting possibility
is that this man may have had a chronic pyelone-
phritis. We know that he had a blood urea nitro-
gen of 41 mg. per cent at that time. On the other
hand, we aren’t told when that BUN was taken,
whether the patient was dehydrated at the time,
nor how much investigation of the kidney was
done. Of course, pyelonephritis can cause a great
number of bizarre abdominal complications. It
can cause an ileus, for example, and can pro-
duce vomiting and bleeding from the gastroin-
testinal tract.

On his second admission here, the patient had
a good appearance. He was slightly jaundiced,
and he had tenderness in the right upper quadrant
and epigastrium which again would make us think
that we had acute cholecystitis or possibly a pene-
trating ulcer. As a rule, we don’t find tenderness
in that region with appendicitis. But there was
no rebound tenderness, and that is a significant
fact. We might interpret his tenderness as more
the result of overdistention of the gallbladder or
pressure on some hollow organ, rather than as
the result of direct involvement of the parietal
peritoneum by inflammation. Advanced peritonitis
does not seem to have been likely at that point.
Rectal examination was negative. The patient’s
laboratory tests were fairly normal. His urea
nitrogen was 19 mg. per cent, and his creatinine
1.0 mg. per cent. The total bilirubin was 3.7 mg.
per cent. He had a rather low urea and a normal
creatinine, from which I believe — and I think Mr.
Butterfield agrees — that most of his azotemia re-
ported later in the protocol probably was pre-
renal in origin.

The patient spiked a fever of 103°F., but soon
after admission and during the rest of his course,
his fever varied from 99° to 102 °F. Pancreatitis
caused by calculus disease of the biliary tract is
a good possibility in this man. It should be noted,
however, that the patient did not vomit early in
his disease. This raises the suspicion of another
lesion in addition to pancreatitis. Pancreatitis sec-
ondary to common-duct stone probably is so obvi-
ous that something else was overlooked.

The frequent vomiting after admission may have
been indicative of some disease of the intestine.
Mr. Butterfield has been thinking of appendicitis,
but I have been thinking of an intestinal obstruc-

tion or possibly of a perforated duodenal ulcer.
Of course, a perforation of the gallbladder is al-
ways possible with acute cholecystitis. The pa-
tient’s urinary output decreased, acidosis was
noted, and his bowel sounds became hypoactive.
Now, we haven’t been told whether there had
been anything significant about the bowel sounds
hitherto. I think it is recorded that they were
heard, but became hypoactive later. This might
constitute evidence of an ileus from peritonitis,
of either chemical or bacterial origin. Later on,
an aspiration from the peritoneal cavity revealed
a dark fluid from which Escherichia coli was cul-
tured. The most common cause for such a culture
would be perforation of the gut.

May we see the x-rays at this time?

Dr. Carl L. Gillies, Radiology : We have the pos-
tero-anterior and lateral films of the chest, which
demonstrate a diffuse fibrosis with pulmonary
emphysema.

The film of the abdomen (we also had an up-
right film that demonstrated no free air within
the abdomen) demonstrated collections of gas
both in the small and in the large bowel. These
findings were interpreted as paralytic ileus. We
do not have the films of the urinary tract.

Dr. Welch: Possibly there was a mechanical ob-
struction of the intestine. This is the small in-
testine, I take it.

Dr. Gillies: Yes, I think so.

Dr. Welch: Isn’t that a rather unusual configura-
tion of it?

Dr. Gillies: Yes, I’d say it is.

Dr. Welch: We must consider a possible volvu-
lus, and we must also consider an adhesive-band
obstruction, for this man had had an operation.
Of course early in acute pancreatitis, the jejunum
is paralytic, and late there often is quite an ex-
tensive ileus. The fact that the small-bowel dis-
tention was localized suggests that he had a me-
chanical obstruction. The type of peritoneal fluid
that was aspirated could very well have been
entirely the result of acute pancreatitis, but the
same sort of thing could also be found in a patient
with a perforated duodenal ulcer or a patient with
a strangulated intestine. This man’s serum amy-
lase was 600 units — quite in keeping with acute
pancreatitis. The drop to 64 was a rather precipi-
tous one in a short period of time, but not unusual.
Finally, the patient had pneumonia, a tracheosto-
my was performed, and he died.

Now my diagnosis is as follows. First, I am go-
ing to put biliary-tract stone — including common-
duct stone, which I think the man had — with pan-
creatitis. A chronic pyelonephritis may have been
present, although not responsible for his symp-
toms. Finally, he had pneumonia.

However, in addition to pancreatitis as the cause
of his intra-abdominal disease, I think he had in-
testinal perforation as a result of intestinal ob-
struction, this obstruction being due to adhesive
bands or volvulus. I don’t think it was due to gall-

300

Journal of Iowa Medical Society

May, 1962

stone obturation, for this man’s story does not fit
with obturation. Then too, of course, I’d like to
give secondary consideration, as Mr. Butterfield
has done, to perforated ulcer or perforated gall-
bladder. I must say that I haven’t thought seri-
ously about appendicitis.

Dr. Buckwalter: Thank you, Dr. Welch.

Perhaps it hasn’t been apparent, but the resi-
dents and staff members who took care of this
man were impressed by the acute nature of the
illness that resulted in his death. The clinical
diagnosis was acute pancreatitis. The number-one
question that concerned the staff was whether or
not the patient should be operated upon. During
the last two days of his life, the answer obviously
was “No.” By that time he was too ill to survive
an operation. Should an operation have been per-
formed during the first two days of his illness?

Dr. Arnold Tammes, Pathology: At the time of
autopsy, no obvious jaundice was present.

The abdomen was quite protuberant, and upon
opening it we found a localized right-upper-quad-
rant peritonitis with 300 ml. of purulent material
in the area. In that site, a loop of distal ileum and
omentum was firmly adherent to the under sur-
face of the liver and gallbladder. There were sev-
eral small areas of necrosis of the ileum, with
intramural abscess formation.

A calculus, 7 mm. in diameter, was found in
the common bile duct. It was located at the am-
pulla, just distal to the point of entrance of the
pancreatic duct into the common bile duct. The
lumen of the common duct was partially occluded
by this calculus, and there was some bile stain-
ing of the gut contents. The duct proximal to the
calculus was dilated. The gallbladder was also
dilated and contained five calculi. Its wall was
thickened and scarred, and chronically inflamed.

The head of the pancreas was slightly firmer
than usual, and on the cut surface there were
numerous small focal areas of necrosis which
measured up to 2 mm. in diameter. Those foci con-
sisted of acute necrosis of adipose tissue and small
amounts of pancreatic tissue, with very little in-
flammatory response present. Thus the lesions had
been of short duration. Most of them appeared
consistent with an age of approximately 24 to 48
hours. No areas of fat necrosis were found outside
of the confines of the pancreas proper.

The liver was somewhat enlarged, weighing
1,940 Gm. Grossly, it showed some acute conges-
tion, and microscopically it also showed intra-
cellular bile stasis and mild bile-duct prolifera-
tion.

The spleen contained an area of fresh infarction
3 cm. in diameter.

The right kidney weighed 220 Gm., and showed
hydroureter and hydronephrosis. The dilated sec-
tion of ureter extended 4 cm. down toward the
bladder, at which point it abruptly became of
normal size. There was no extrinsic obstruction,
and it is felt that the defect was congenital. The

left kidney weighed 180 Gm. and had duplication
of the collecting system and upper 3 cm. of ureter,
from which point the ureters combined to form
a single, normal-sized ureter. The postmortem
blood urea nitrogen was 125 mg. per cent, and
the creatinine was 7.3 mg. per cent. Microscopically,
the kidneys showed moderately severe nephro-
sclerosis and some tubular changes consistent with
a mild degree of lower nephron nephrosis.

The lungs were very heavy. The right lung
weighed 880 Gm., and the left one weighed 1,000
Gm. The bronchial tree contained considerable
amounts of purulent material. Both grossly and
microscopically, the lungs demonstrated diffuse,
severe fibrosis, patchy atelectasis, severe hemor-
rhage and bronchopneumonia. There were large
amounts of anthracotic-like pigment scattered
throughout the lungs, which gave them an almost
homogenous black appearance.

I should like to postulate the chain of events
leading up to the death of this patient. Old ad-
hesions between the ileum and the gallbladder re-
gion, I think, resulted from the previous gall-
bladder disease and surgery. Biliary colic that
was present at the time of his last admission gave
rise to a mild adynamic ileus. X-rays of the abdo-
men revealed that finding. The ileus gave rise to
distention of the bowel in the area of the adhe-
sions. Then, either overdistention or twisting of
this fixed area of the bowel probably resulted in
vascular compromise, with resultant edema and
further vascular compromise. Finally, some areas
must have become so compromised that the wall
of the bowel became pervious to organisms within
the abscesses of the lumen and bowel wall, and
the localized peritonitis was established. Superim-
posed upon this was the severe pulmonary fibrosis,
pneumonia and severe hemorrhage that represent
the immediate cause of death. The pancreatitis
appears to have been very recent and mild, and of
relatively less importance than the bowel and pul-
monary findings.

Dr. Buckwalter: There is an inaccuracy in the
protocol, and though I don’t think it influenced
Dr. Welch’s discussion, it is important in that it
illustrates a problem that frequently confronts
surgeons. Chronic cholecystitis and cholelithiasis
were diagnosed in this man when he was seen in
1952. It is not altogether clear why surgery was
not done at that time. Presumably, the episode of
pyelonephritis, his enlarged heart and his 77 years
of age were the factors that caused the surgeons
who saw him at that time to rule against opera-
tive intervention. Viewed in retrospect, their de-
cision seems to have been wrong.

Though the protocol doesn't say so, he was seen
later by the Orthopedic Department for treatment
of a fractured femur. Actually, there were three
subsequent admissions relative to the fracture.
No reference was made to the gallbladder disease.
Apparently nine years and four University Hos-
pitals admissions passed before he experienced any

Vol. LII, No. 5

Journal of Iowa Medical Society

301

further gallbladder difficulties. Hindsight suggests
that an earlier operation would have circumvented
the fatal episode, but this is a matter of specula-
tion, and it is possible that he wouldn’t have sur-
vived the operation.

Dr. Welch, I wonder whether you have any
comments to make in this connection. What about
the indications for operation in a case like this?
Do you feel that there is an indication for gall-
bladder removal in a patient who has had a chol-
ecystostomy?

Dr. Welch: I believe there is. As I said, the
studies show that in almost all cases in which
cholecystostomy has been done, stones can be
found two or three years later. There are two
reasons why they do. Sometimes they haven’t all
been removed, and even when one succeeds in
getting them all, a cholecystostomy leaves the
“quarry.” More stones will form. Furthermore,
the clear-cut indication in this man, I think, was
that he had had a common-duct stone originally,
one that had been there for many years, and
therefore I think he had more than the usual indi-
cation for secondary surgery on his biliary tract.
He showed jaundice when he came in, and I think
that would have been a good indication.

There are two or three other points that I might
spend a few minutes on. One is this question of
operating in acute pancreatitis. Everyone is so
firmly determined not to operate during acute
pancreatitis that misdiagnosis is a serious affair.
If the patient with symptoms and signs suggestive
of pancreatitis does not have that disease, he usu-
ally has one that requires early remedial sur-
gery. It is not a great error to explore a patient
with pancreatitis. True, you have not helped him,
but you probably haven’t harmed him. If doubt
exists, exploration is justified. The cases of severe,
fulminating, hemorrhagic pancreatitis destined to
end fatally are not influenced by an exploration.
Survival depends upon the supportive therapy,
and the patient can be supported just as well
with an operation as without. The point is that
operating probably does not greatly increase the
mortality of pancreatitis.

Keep in mind that we can’t always be certain
of the diagnosis of acute pancreatitis. A high
serum amylase can be caused by other diseases,
and one should beware of accepting such a test
result as evidence only of pancreatitis. Values for
amylase in the blood rise in perforated duodenal
ulcer, intestinal obstruction with gangrenous
bowel, and other lesions.

I think there are aspects of this case that should
teach us something. One of them is the plain film
of the abdomen. I think it is suggestive of a local
obstruction, and therefore a mechanical one. It
doesn’t look like an ileus. The other significant
finding was the peritoneal fluid obtained bj^ aspi-
ration. That fluid is most typical of an intestinal
leak or a contamination.

Dr. Buckwalter: Am I correct, Dr. Tammes,

that you think the rather mild pancreatitis was
not the important factor in causing the patient’s
death, and that his most important problem was
cholecystitis?

Dr. Welch: The principal lesion was strangula-
tion of the bowel, wasn’t it?

Dr. Tammes: Yes.

Dr. Buckwalter: The loop of small bowel ad-
herent to the inflamed gallbladder was the in-
flammatory mass underneath the right lobe of the
liver?

Dr. Tammes: Yes, and it goes back to the pa-
tient’s gallbladder trouble and his first surgery.

Dr. Buckwalter: You postulated that that loop
of bowel had been there for nine years, Dr. Welch,
and that the acute inflammatory process in the
gallbladder finally caused obstruction, which in
turn led to strangulation?

Dr. Welch: From the pathologist’s description,
I think that an adhesive-band strangulation or a
volvulus had occurred.

Dr. Tammes: Yes, that is correct. The adhesive
bands were very dense, and thus it seemed that
they were quite old. They weren’t recently-formed
adhesive bands.

Dr. Buckwalter: Our clinical diagnosis was
wrong. We misinterpreted the physical findings
that were almost classic for acute pancreatitis.

We recently heard an exposition on the subject
of pancreatitis by Dr. John Howard, and this case
fits well into the classification “gallbladder pancre-
atitis.” Dr. Howard made the point that if you
can make the differential diagnosis between al-
coholic and gallbladder pancreatitis, there is no
indication for operation. From your discussion,
I assume that you entirely agree with him. Am I
correct, Dr. Welch?

Dr. Welch: Let’s put it this way. I don’t dis-
agree with Dr. Howard. I fully agi'ee that one
can’t help the alcoholic type of pancreatitis by
operating, but I think one shouldn’t hesitate to
explore doubtful cases of pancreatitis. Abdomen
comes from a Greek word meaning hidden, and
that fact may be significant. One sometimes must
operate to make sure of the diagnosis.

Dr. Sidney E. Ziffren, Surgery: I was interested
in the fact that this patient displayed an Opie
syndrome— a stone plugging the ampulla of Vater
and blocking both the common bile and main pan-
creatic ducts. This represents the classic “common
channel” theory as to the cause of acute pancreatitis.
Dr. Foster, in our department, has reviewed our
cases of severe acute pancreatitis. His study
did not include the common type of pancreatitis
which is accompanied by an elevation in serum
amylase but only minimal abdominal symptoms
and signs, and which subsides in 24 to 48 hours.

One must remember that there are many medi-
cal conditions that can elevate the serum amylase.
A few examples are azotemia, parotitis, alcohol-
ism, pneumonia and viral hepatitis. The amy-
lase may also be elevated following the adminis-

302

Journal of Iowa Medical Society

May, 1962

tration of chlorothiazide or ACTH. Opiates are
notorious for elevating the serum amylase level.
Then there are a host of surgical causes other
than pancreatitis that elevate the amylase level,
for instance perforated ulcer, mesenteric throm-
bosis with infarction, high intestinal obstruction,
and peritonitis of almost any degree.

At any rate, Dr. Foster’s study covered those
cases in which the patients had a severe illness
with an elevated amylase, or in whom pancre-
atitis had been proved at surgery or at autopsy.
In those patients who were operated upon, he
found that the mortality rate had been 48 per cent,
and in the patients who had had no operation, he
found there had been the same mortality rate.
Thus we came to the conclusion that surgery did
not help, but we couldn’t prove that conservative
medical therapy had helped, either.

Three patients in that series had had an Opie
type of mechanism. One patient came to autopsy
after conservative therapy. Another patient was
operated upon and was found to have a stone im-
pacted in the ampulla. In order to remove it, the
operator cut the sphincter. Postoperatively, the
patient developed severe pancreatitis and died.
The third patient was operated upon during an
episode of acute pancreatitis, and was found to
have a stone at the ampulla. The operator was
able to push it through into the duodenum. That
patient also died. Thus, one must come to the
conclusion that this is a very serious condition,
but one that fortunately doesn’t occur very often.

In this patient who did have the disease, edema-
tous pancreatitis was present, and it is much more
common than the hemorrhagic or necrotic form.
Actually, we don’t have much to offer such a
patient from a surgical viewpoint. We must as-
sume that once the mechanism has started, there
is no surgical procedure presently available that
can stop it. If it is going to stop, it will do so
spontaneously.

After reading the protocol, I believe the reason
why this patient wasn’t operated upon in 1952
was that someone thought him too old to with-
stand an operation. Obviously, this patient had a
serious disease, including jaundice. I want to re-
mind you that when this decision was made the
patient was 76 years old. His life expectancy with-
out disease was over eight years. I don’t believe it
represents good judgment to deprive such a pa-
tient of the opportunity for cure.

One of the procedures done on this patient was
a paracentesis — -a very helpful method of es-
tablishing a diagnosis. If one withdraws fluid by
means of an abdominal tap and it has a high
amylase level but in addition is cloudy, bile
stained or foul smelling, you can rest assured that
it is not coming from pancreatitis but from some
other serious surgical disease. If it is clear or
serosanguineous, or if it approaches deep purple-
red in color, and if no organisms are present
when one examines a smear of it, then it is very

likely that the patient has pancreatitis. We don’t
use this procedure often enough. It can be quite
helpful.

But as Dr. Welch has said, one mustn’t permit
his clinical judgment to be so warped by a labora-
tory figure that he fails to do what should be
done. I am sure that he is right when he says
that in a patient who has hemorrhagic or necrotic
pancreatitis, exploration probably doesn’t do very
much to change the mortality figures.

Dr. Robert C. Hickey, Surgery: I’d like Dr.
Tammes to tell us to what degree he thinks the
pancreatitis contributed to the fatal outcome in
this case. I’m not sure I understand where the
pancreatitis fitted in.

Dr. Tammes: I think the findings indicate that
the pancreatitis was so recent and relatively mild
that it should be regarded as a coincidental finding
— as a condition that contributed little to the fatal
outcome.

Dr. Hickey: What was the cause of death, as
viewed by the pathologists?

Dr. Tammes: Pulmonary complication of bron-
chopneumonia and extensive hemorrhage into the
lungs.

Dr. Hickey: And the kidney?

Dr. Tavimes: Contributory, but not intimately
so.

Dr. Buckwalter : And peritonitis?

Dr. Tammes: Intimately associated.

Dr. Buckwalter: This case provides a fitting end
for a postgraduate course in surgery. Most of the
discussion during the past hour suggests the im-
portance of an aggressive approach to these pa-
tients.

I’m wondering whether we can have some com-
ments from our colleagues who don’t use the
aseptic scalpel.

Dr. Henry E. Hamilton, Internal Medicine: Con-
servative management is preferable if the signs,
symptoms and laboratory findings are consistent
with acute pancreatitis, but after the evidence
presented here this afternoon, I think that if there
are any discordant findings the surgeon should
stop turning the differential diagnosis over in his
mind and should take a look! Let’s face it. We
often have trouble getting you folks to “explore.”
We are not really conservative with your surgical
skill!

Dr. Buckwalter: I wonder whether everyone in
this room knows that you had one year as a resi-
dent in surgery.

Dr. William B. Bean, Internal Medicine: And
then he started thinking.

Dr. Buckwalter: Are there any comments or
questions from the doctors who are visiting us
today?

The meeting is adjourned.

PATHOLOGIC DIAGNOSES

Peritonitis, localized, right upper quadrant

Patchy necrosis of ileum

Vol. LII, No. 5

Journal of Iowa Medical Society

303

Chronic cholecystitis and cholelithiasis

Choledocholithiasis

Pulmonary fibrosis and anthracosis

a. bronchopneumonia

b. hemorrhage (terminal event)

Fat necrosis of pancreas, acute
Splenic infarct

Mild lower nephron nephrosis
Reduplicated calceal and pelvic systems, left
kidney

Congenital hydronephrosis, right kidney.

STUDENTS' DIAGNOSES

Cholecystitis with cholelithiasis and acute pan-
creatitis.

DR. WELCH'S DIAGNOSES

Biliary tract stone and common duct stone, with
pancreatitis

Pneumonia

Intestinal perforation as a result of obstruction
due to adhesive bands or volvulus.

CLINICAL DIAGNOSIS

Acute pancreatitis.

Coming Meetings

May 13-16
May 23

June 18-21

May 1-2
May 1-3

May 1-5
May 3-5
May 3-5

May 4-5
May 4-6
May 4-7
May 5-9

May 6-10
May 6-10
May 7-11
May 7-11
May 7-11
May 8-10
May 9-11

May 9-12
May 9-13
May 10-11
May 10-12
May 13-17
May 14

May 14-16

May 14-17

IOWA

Annual Meeting of the Iowa Medical Society.
Veterans Auditorium and Savery Hotel, Des
Moines

Symposium, afternoon and evening (Lee
County Medical Society and the Iowa Chap-
ter of the American Academy of General

Practice). Golf and Country Club, Fort Mad-
ison

Spring Postgraduate Conference (Iowa Chap-
ter of the American Academy of General

Practice). The New Inn, Lake Okoboji

CONTINENTAL U. S.

American Broncho-Esophagological Associa-
tion. Sheraton-Dallas Hotel, Dallas
American Laryngological, Rhinological and
Otological Society, Inc. Sheraton-Dallas Hotel,
Dallas

American Laryngological Association. Shera-
ton-Dallas Hotel, Dallas

Society of Biological Psychiatry. Royal York
Hotel, Toronto, Canada

American Society for Microbiology. Muehle-
bach Hotel, Kansas City, Missouri
American Association of Plastic Surgeons.
Hotel Del Coronado, Coronado, California
American Psychiatric Association. Royal York
Hotel, Toronto, Canada

American Association of Genito-Urinary
Surgeons. Skytop Lodge, Skytop, Pennsylva-
nia

American Thyroid Association. Roosevelt Ho-
tel, New Orleans

Student American Medical Association. May-
flower Hotel, Washington, D. C.

American Pediatric Society. Traymore Hotel,
Atlantic City

Ear, Nose and Throat. University of Califor-
nia, San Francisco

Annual Meeting of the Illinois State Medical
Society. Hotel Sherman, Chicago
Medical Alumni Seminar (University of Il-
linois College of Medicine). Hotel Sherman,
Chicago

Fundamental and Applied Aspects of Cardiol-
ogy (American College of Physicians). Wayne
State University College of Medicine, Detroit
American Urological Association. Bellevue-
Stratford Hotel, Philadelphia

May 14-17

May 14-18
May 14-18

May 14-18

May 15

May 15-16

May 16-19

May 17-18
May 20-23

May 20-25
May 21-23

May 21-24
May 21-25

May 21-25
May 21-25
May 24-26
May 26
May 26-30
May 28-30

May 28-30
May 28-30

May 29- June 2
May 31 -June 2

June 1-2
June 1-3

June 1-29

June 2

June 4-8

Surgery. University of Kansas School of Med-
icine, Kansas City, Kansas
American Nurses’ Association. Detroit
Vaginal Approach to Pelvic Surgery. Cook
County Graduate School of Medicine, Chicago
Blood Vessel Surgery. Cook County Graduate
School of Medicine, Chicago
Rehabilitation in the Older Patient. University
of Kansas School of Medicine, Kansas City,
Kansas

International Symposium on “Injury, Inflam-
mation and Immunity” (Research Depart-
ments of Miles Laboratories, Inc.). Elkhart,
Indiana

Expanded Surgery of the Nasal Septum and
Closely Related Structures (American Rhi-
nologic Society). St. Michael Hospital, Mil-
waukee

Proctology. University of California, San
Francisco

57 th Annual Meeting, American Thoracic
Society. Deauville and Carillon Hotels, Miami
Beach

National Tuberculosis Association. Deauville
Hotel, Miami Beach

109th Annual Meeting of the Minnesota State
Medical Association. Hotel Leamington and
the Minneapolis Auditorium, Minneapolis
Catholic Hospital Association Convention. Kiel
Auditorium, St. Louis

Inhalation Therapy. Stanford University
School of Medicine, Palo Alto, California
American Society of Maxillofacial Surgeons.
Montreal, Canada

Tenth Annual Western Cardiac Conference.
University of Colorado Medical Center, Den-
ver

American Ophthalmological Society. The
Homestead, Hot Springs, Virginia
First Annual Convention of the American As-
sociation for Contamination Control. Jack Tar
Hotel, San Francisco

American College of Cardiology. Denver Hil-
ton Hotel, Denver

American Gynecological Society (Members and
Invited Guests). The Homestead, Hot Springs,
Virginia

Medical Emergencies. U.C.L.A., Los Angeles
Back Pain. University of California, San Fran-
cisco

Internal Medicine. Harvard Medical School,
Boston

Lederle Symposium. Davenport Hotel, Spo-
kane, Washington

Surgery of Colon and Rectum. Cook County
Graduate School of Medicine, Chicago
Psychiatry for the Internist (American Col-
lege of Physicians). The Psychiatric Institute,
University of Maryland School of Medicine,
Baltimore

304

Journal of Iowa Medical Society

May, 1962

June 4-8
June 4-9
June 4-9
June 4-15
June 4-22
June 4-22

June 7-9

June 10-16

June 11-16

June 11-22

June 14-17

June 17-23

June 18-20

June 18-22

June 21-22

June 21-23

June 21-23
June 21-24

June 21-25

June 22-23
June 22-24
June 23

June 23

June 23
June 23

June 23-24
June 24
June 24
June 24-28
June 25-27
June 25-29
June 25-July 6

June 27-30
June 28-30

May

May-June

Hematology. Cook County Graduate School of
Medicine, Chicago

Histochemistry. University of Kansas Medical

Center, Kansas City, Kansas

Basic Science and Its Relation to Internal

Medicine. Harvard Medical School, Boston

Surgical Technic. Cook County Graduate

School of Medicine, Chicago

General Surgery. Harvard Medical School,

Boston

Forty-seventh Annual Postgraduate Session of
the Trudeau School of Tuberculosis and Other
Pulmonary Diseases. Saranac Lake, New York
Corneal Lens: Theory and Application. Uni-
versity of California. San Francisco
General Surgery. University of Nebraska Col-
lege of Medicine, Omaha

Histochemistry. University of Kansas Medical
Center, Kansas City, Kansas
Fractures and Traumatic Surgery, Cook Coun-
ty Graduate School of Medicine, Chicago
Neuromuscular Diseases. Cook County Grad-
uate School of Medicine, Chicago
American Electroencephalographic Society.
Claridge Hotel, Atlantic City
Obstetrics and Gynecology. University of Ne-
braska College of Medicine, Omaha
American Geriatrics Society. Palmer House,
Chicago

American Neurological Association. Claridge
Hotel, Atlantic City

Gallbladder Surgery. Cook County Graduate
School of Medicine, Chicago
Advanced Electrocardiography. Cook County
Graduate School of Medicine, Chicago
Canadian Medical Association. Royal Alexan-
dria Hotel, Winnipeg

Annual Educational Conference, National As-
sociation of Sanitarians. Cincinnati
American Rheumatism Association. Edgewater
Beach Hotel, Chicago

Surgery of Hernia. Cook County Graduate
School of Medicine, Chicago
Endocrine Society. Palmer House, Chicago
American Therapeutic Society. McCormick
Place, Chicago

Twenty-eighth Annual Meeting of the Amer-
ican College of Chest Physicians. Morrison
Hotel, Chicago

Urology. Stanford University School of Med-
icine, Palo Alto, California

International College of Angiology. Conrad
Hilton Hotel, Chicago

Community Preparedness for Emergencies —
Tenth Annual National Conference on Disas-
ter Medical Care (AMA). Palmer House,
Chicago

International Cardiovascular Society, North
American Chapter. Conrad Hilton Hotel,
Chicago

American Academy of Tuberculosis Phy-
sicians. Palmer House, Chicago
Annual Meeting of the American Association
for the Study of Headache. Palmer House,
Chicago

American Diabetes Association, Inc. Conrad
Hilton Hotel, Chicago

Society for Vascular Surgery. Conrad Hilton
Hotel, Chicago

Society for Surgery of the Alimentary Tract.
Sheraton-Chicago, Chicago

111th Annual Meeting of the American Med-
ical Association. Chicago

Obstetrics and Gynecology. University of

Colorado Medical Center, Denver

Vaginal Surgery. Cook County Graduate

School of Medicine, Chicago

Electrical Technics in Biology and Medicine

(Case Institute of Technology). University

Circle, Cleveland

Ninth Annual Meeting, Society of Nuclear
Medicine. Baker Hotel, Dallas
International Conference on Opportunistic
(Secondary) Fungus Infections. Durham, North
Carolina

ABROAD

World Health Organization, Palais de Nations,
Geneva, Switzerland. Write: Secretary-Gen-
eral, World Health Organization, Palais de
Nations, Geneva

May 3-6 106th Annual Meeting of the Hawaii Medical

Association, Honolulu.

May 4-6 International Society of Ski Traumatology and

Winter Sports Medicine. Obergurgl, Tyrol,
Austria. Write: Professor Dr. Wolfgang Baum-
gartner, Chirurg. University Klinik, Innsbruck,
Austria

May 13-19 World Congress of Gastroenterology, Munich,
Germany. Write : Medizinische Universitats-
klinik, Krankenhausstrasse 12, Erlangen, Ger-
many

May 14-18 International Congress on Hormonal Steroids,
Milan, Italy. Professor L. Martini, Institute de
Farmacologia e Terapia, 21 Via A. del Sarto,
Milan

May 15-19 Congress of the European Federation (Inter-
national College of Surgeons). Amsterdam,
The Netherlands

M.D., Associate Dean, Postgraduate Division,
U.S.C. School of Medicine, 2025 Zonal Ave.,
Los Angeles 33

May 26-30 International Congress for Hygiene and Pre-
ventive Medicine. Vienna, Austria. Write:
Med. -Rat Dr. Ernst Musil, Mariahilferstrasse
177, Vienna 15

May 27-31
June 16-21

July 1-4

July 8-12

July 28-
Aug. 3

July 30-
Aug. 13

Aug. 8-15
Sept. 3-7

Sept. 5-8

Sept.

Oct.

Oct. 7-13
Oct. 22-28

Nov. 11-16
Dec.

Feb. 20-24,
1963

American Orthopaedic Association (Members).
Castle Harbor Hotel, Bermuda
International Symposium on Enzymic Activity
in the Central Nervous System, Goteborg,
Sweden. Write: Dr. A. Lowenthal, Institut
Bunge, 59 rue Philippe Williot, Berchem-
Antwerp, Belgium

International Conference on Oral Surgery.
Royal College, London. Write: D. C. Trexler,
Executive Secretary, American Society of Oral
Surgeons, 840 North Lake Shore Drive, Chica-
go 11

International Congress of Psychosomatic Med-
icine and Childbirth. Paris. Contact: Dr. L.
Chertok, 22 rue Legendre, Paris 17, France
Pan American and South American Pediatric
Congress. Quito, Ecuador. Write: Dr. Jorge
Vallarino, P.O. Box 2269, Quito, Ecuador
Fifth Annual Refresher Course (University
of Southern California). Royal Hawaiian
Hotel, Honolulu, and on S. S. Matsonia. Ad-
dress: Phil R. Manning, M.D., Associate Dean
Postgraduate Division, U.S.C. School of Med-
icine, 2025 Zonal Avenue, Los Angeles 33
International Fertility Association, 4th World
Congress, Hotel Copocabana, Rio de Janeiro.
Write: Dr. Maxwell Roland, Secretary, 109-23
71st Road, Forest Hills 75, New York
First International Conference on Water Pol-
lution Research. London. Write: Mr. W. Wes-
ley Eckenfelder, Jr., Manhattan College En-
vironmental Engineering Research Laboratory,
514 Sylvan Avenue, Englewood Cliffs, New
Jersey

International Congress of Internal Medicine,
Munich, Germany. Write: Professor Dr. E.
Wollheim (President of Congress), Luitpold-
krankenhaus, Wurzburg, Germany
International Congress of Infectious Pathol-
ogy, Bucharest, Rumania. Write: Professor S.
Nicolau, Via Parigi, 7-Bucharest
Third International Conference on Alcohol
and Road Traffic, London. Write: Mr. J. D. J.
Havard, Secretary, Committee on Manage-
ment, British Medical Association House, Tavi-
stock Square, London

American Society of Plastic and Reconstruc-
tive Surgery, Hawaiian Village Hotel, Hono-
lulu. Write: T. Ray Broadhent, M.D., Sec-
retary, 508 East South Temple, Salt Lake City
World Congress of Cardiology, Medical Cen-
ter, Mexico City. Write: Dr. I. Costero, In-
stitute N. De Cardiologia, Avenida Cuauhte-
moc 300, Mexico 7, D. F.

International Medical World Conference on
Organizing Family Doctor Care. Victoria Halls,
Southampton Row, London. Write: The Editor,
The Medical World, 56 Russell Street, Lon-
don, W.C.I.

Vol. LII, No. 5

Journal of Iowa Medical Society

305

Causes of Death Following Burns

A report by Phillips and Cope1 on the causes of
death in patients with burns at Massachusetts Gen-
eral Hospital over a 20-year period reflects the
changes that have been brought about by im-
proved methods of treatment. The records of 1,140
patients admitted between 1939 and 1957 were ex-
amined, and the case records of 932 of them were
studied in detail. Death had occurred in 106 cases,
and the clinical records, laboratory findings, x-ray
reports and, when available, autopsy findings were
considered in an effort to detect the cause of death
in each instance.

In 1939 and shortly thereafter, 20 per cent of
all deaths from burns were the results of shock,
and the patients died within the first 25 hours.
From 1948 to 1957, only one patient, a woman
with burns over 95 per cent of her body, was
thought to have died of shock. Of the 11 other
deaths that occurred within the first two days, 8
were attributed to respiratory damage, 2 to con-
gestive failure and 1 to a cerebrovascular accident.
It thus is apparent that shock has greatly declined
in importance as a cause of death in burn cases
during recent years.

An apparent doubling of deaths from wound
sepsis in 1948, as compared with the 1939-1947
period, is actually an artifact due to the lengthen-
ing of the survival time in patients with fatal
burns. During the earlier period, the survival time
in fatal cases averaged 4.6 days, in contrast with a
survival time of 15.7 days during the 1948-1957
period. In the earlier decade, wound sepsis ac-
counted for 9.0 per cent of 52 deaths, whereas in
the later period, wound infection killed 20 per cent
of those who died from burns. It is the increased
survival time that was responsible for the in-
creased prominence of wound sepsis in the first
six days, and the elimination of all patients who
died within the first six days in both periods
abolishes the apparent increase in the incidence
of fatal wound sepsis. If only those patients who
survived beyond six days are considered, the death
rate from wound sepsis in the early period is in-
creased from 9.0 per cent to 35.0 per cent, and the
rate for the 1948-1957 period becomes 33 per cent.

The deaths of 45 per cent of all those fatally
burned during the 20 years were caused by respir-
atory damage, with or without infection. Bron-

chopneumonia was a terminal event in many pa-
tients who died from other causes. In 1934-1947,
respiratory-tract damage killed twice as many
patients as did shock, and between 1948 and 1957,
it killed 22 times as many. The increase in this
ratio was the result, however, of the drop in num-
bers of deaths from shock, rather than an increase
in the incidence of damage to the respiratory tract.
Respiratory-tract damage has remained almost
constant, with or without infection in the damaged
respiratory tract. Forty -three per cent succumbed
from this cause in the early years covered by this
study, and 42 per cent in the later decade. A study
of the survival times reveals that with a single
exception all patients having respiratory damage
in either period developed superimposed sepsis if
they lived more than 72 hours. Thus, the prime
killer of the burn patient is and has been for two
decades respiratory-tract damage.

According to the report from Massachusetts
General Hospital, deaths from uremia are on the
increase among burn patients, even though the
mortality in the shock phase has been cut in two.
In patients surviving beyond eight days, one of 11
patients died of uremia in the first of the two dec-
ades. In 1948-1957, of 22 patients who survived be-
yond the eighth day, three died of uremia alone,
and one died from uremia and wound sepsis. Eight
patients in the two periods who succumbed to car-
diac complications had preexisting cardiac disease.
Pulmonary emboli caused the deaths of three pa-
tients during the 20-year period, and were found
in at least seven more patients. In at least three
and possibly in all four patients with phlebitis, the
vein had been used for venoclysis. Massive adrenal
hemorrhage accounted for the death of one patient
in the early period, and in four other cases adrenal
hemorrhage, found at autopsy, may have con-
tributed to the fatal outcome. A small number of
deaths were ascribed to preexisting illnesses, asso-
ciated injuries and additional complications.

Phillips and Cope concluded that respiratory-
tract damage was the major killer of the burned
patient, and that the mortality from that cause had
not improved in the 20-year period. Evans2 stated,
in 1952: “In our clinic in the past year, respira-
tory-tract burn was responsible for fully half of
the deaths.” Despite the use of antibiotics, of
tracheotomy, of suction, of oxygen and of steroids,
there has been no improvement in the mortality
from that cause.

Death from shock in the burned patient is now
quite uncommon. Evans outlined the treatment of
shock in the burned patient, and greatly influenced
the management of that condition. Reports from
various centers, however, have described specific
programs that differ in certain details from the
regime of Evans in regard to the amount of fluid,
the type of electrolyte used and the nature of the
colloid administered.

The authors from Massachusetts General Hos-
pital stated that the increase in fatal wound in-

306

Journal of Iowa Medical Society

May, 1962

fections and respiratory-tract sepsis is related to
the survival time. Though the increase in survival
time is encouraging, to lose a patient from sepsis
after weeks of survival emphasizes the need for
controlling that condition. MacMillan3 recom-
mended in 1958 that all confluent areas of full-
thickness burns involving at least 25 per cent of
the body surface be excised. He reported on his
experience with that method and with either
autograft or homograft coverage performed im-
mediately or 48 hours after excision. In his series
of cases, the mortality rate in the excised group
was 42 per cent, as compared with 75 per cent in
the group treated by conventional methods. He
concluded that early excision and early coverage
influenced the incidence of septicemia.

Ravdin4 stated: “In burns of limited extent that
are obviously full-thickness burns, early excision
and grafting is the best treatment. In the patient
with extensive burns, the additional trauma of
anesthesia and operation may be contraindicted
in the early stages of the burn. Excision of the
dead skin, however, once carried out, will improve
the patient’s condition at any stage. It is then a
question of balancing these two factors with the
fact that obvious full-thickness burns should be
excised as soon as the patient can stand the opera-
tion.” Farmer5 and Hyroop,6 among others, have
also emphasized the importance of early excision
and early coverage in the prevention of wound in-
fection.

A second- or third-degree burn over more than
10 per cent of the body surface should be con-
sidered a major injury. The successful treatment
of the severely burned patient taxes the skill and
the judgment of a team of physicians who are
dedicated to the management of that condition.
With the increased survival times of burned pa-
tients, it appears that perhaps early excision and
early coverage may be increasingly important in
reducing the incidence of death from infection.

REFERENCES

1. Phillips, A. W., and Cope, O.: Bum therapy: II. revela-
tion of respiratory-tract damage as principal killer of burned
patient. Ann. Surg., 155:1-19, (Jan.) 1962.

2. Evans, E. I.: Early management of severely burned pa-
tient. Surg., Gynec. & Obst., 94:273-282, (Mar.) 1952.

3. MacMillan, B. G.: Early excision of more than 25 per
cent of body surface in extensively burned patients. AMA
Arch. Surg., 77:369-375, (Sept.) 1958.

4. Ravdin, I. S.: Current status of therapy of burns.

J.A.M.A., 171:1357-1358, (Nov. 7) 1959.

5. Farmer, A. W.: Management of burns in children. Pedi-
atrics, 25 :886-895, (May) 1960.

6. Hyroop, G. L.: Importance of early coverage in treat-
ment of burns. J. Int. Coll. Surg., 34:363-367, (Sept.) 1960.

YOU'LL HEAR ABOUT . . .

. . . the future of cancer chemotherapy . . .
at the

IMS ANNUAL MEETING
May 13-16, 1962

Veterans Memorial Auditorium, Des Moines

New Adverse Reaction to the
Tetracyclines

The wide use of the tetracyclines has given rise
to several side effects with which most clinicians
are familiar. The commonest of these has been
gastroenteritis, but angioneurotic edema, skin
rashes and anaphylaxis are rarer complications
that have been reported. Now John P. Fields,* of
the Vanderbilt School of Medicine, has called at-
tention to another adverse reaction with which
physicians who treat infants should become famil-
iar. Tetracy line-induced intracranial pressure, with
bulging of the anterior fontanel, had been ob-
served by members of the Vanderbilt pediatric
staff, and Lewis reported in detail on two infants
with the complication who were studied at that
hospital.

A four-month-old baby boy who had been ill for
36 hours with cough, fever and loss of appetite, was
seen by a physician and a diagnosis was made.
Tetracycline was given in a dosage of 50 mg. every
six hours. When the infant was seen initially, the
anterior fontanel had been examined and had been
normal. Twelve hours later, however, after four
doses of the antibiotic, he vomited and became
irritable, and examination by the physician re-
vealed a markedly bulging fontanel. When ad-
mitted to the hospital, the baby was lethargic, and
the tense fontanel was again observed. Lumbar
puncture revealed a clear spinal fluid under in-
creased pressure. There were no cells, and cul-
tures were sterile. The spinal fluid sugar and pro-
tein were normal. Bilateral subdural taps were
done, but no fluid was obtained. Roentgenograms
of the skull showed questionable spreading of the
sutures, and the bulging fontanel was noted. The
administration of tetracycline was discontinued,
and the patient was observed for 48 hours. Im-
mediately after the lumbar puncture, the bulging
fontanel returned to normal. The infant remained
afebrile and made a prompt recovery, with no
recurrence of the intracranial hypertension.

A second patient, a six-month-old baby girl
with bronchitis who had been ill for four days, was
started on tetracycline phosphate complex in a
dose of 50 mg. every six hours, and upon her ad-
mission to the hospital it was noticed that the
fontanel was tense and bulging. The cerebrospinal
fluid was clear and contained one white cell per
cubic milliliter. The spinal fluid sugar and protein
were normal, and the culture was negative. The
tetracycline was discontinued, and chloramphenicol
was substituted for it. The bulging of the fontanel
disappeared within a few hours and did not recur.

The relationship between tetracycline therapy
and increased intracranial pressure appeared to
be more than mere coincidence. Withdrawal of the

* Fields, J. P. : Complication of tetracycline therapy in in-
fants. j. pediatrics, 58:74-76, (Jan.) 1961.

Vol. LII, No. 5

Journal of Iowa Medical Society

307

drug was associated with a prompt return of the
fontanel to normal. There was no correlation be-
tween either the dosage of the drug or the dura-
tion of therapy and the bulging of the fontanel.
There was no evidence of meningitis or subdural
hematoma in either patient, and otitis media was
not present.

Careful evaluation of patients with bulging
fontanels should be carried out, and other causes
should be excluded before a diagnosis of tetracy-
cline reaction is made. Bulging of the fontanel
ordinarily has serious implications, and in infants
receiving tetracycline therapy this newly dis-
covered complication should be considered in the
differential diagnosis. Awareness of this adverse
reaction may spare the physician some very anx-
ious moments.

The Guillain-Barre Syndrome

The Guillain-Barre syndrome is an acute poly-
radiculoneuropathy with progressive motor and
sensory disturbance of the cranial and spinal
nerves, and with an albuminocytologie dissociation
of the spinal fluid. Though the elevation of the
spinal fluid protein, with no increase in the spinal-
fluid cell count, is well recognized in this interest-
ing neurologic disease, the pathologic process
which gives rise to it is not generally known or
understood. In 1958, Berlacher and Abington1 pre-
sented a concise description of the pathology, giv-
ing a clear explanation for the neurologic findings,
the high spinal-fluid protein and the normal cell
count.

According to Berlacher and Abington, the out-
standing feature of the pathology in Guillain-Barre
syndrome is the pronounced edema of the nerve
fibers of the spinal roots and the proximal portions
of the cranial and peripheral nerves. A similar
edematous involvement of the spinal-cord tracts
has been described. The edema of the axones
leads to a narrowing and obliteration of the peri-
neural spaces and, if severe, to a strangulation of
the radicular nerve trunks. As a result of the
strangulation there is a degeneration of the myelin
sheaths, with a loss of nerve-fiber function. This
leads to a flaccid paresis or paralysis, with loss of
reflexes and characteristic sensory disturbances.
The inflammation which has been described in
the peripheral nerves can be explained as being
secondary to cellular and myelin-sheath degenera-
tion.

The obliteration of the perineural spaces blocks
the absorption of spinal fluid along these channels,
and results in a strangulation and trapping of the
fluid within the subarachnoid space. The result is
comparable to that of a spinal-fluid block produced
by a space-occupying lesion. The obstruction per-
mits the escape of water and electrolytes, but not

of the large protein molecules, thus producing the
albuminocytologie dissociation. Capillary damage
may be a contributing factor, resulting in increased
permeability and leakage of protein into the spinal
fluid. The normal spinal-fluid cell count is attri-
buted to a minimal inflammatory involvement of
the meninges.

Osier and Sidell2 have pointed out that there is
need for more exact criteria for the diagnosis of
the Guillain-Barre syndrome, because the diagno-
sis has become confused by the inclusion of many
types of polyneuritis. It is urged that the designa-
tion “Guillain-Barre syndrome” be restricted to
those cases that conform with a characteristic clin-
ical picture, course and prognosis.

According to the Boston physicians, there are
12 criteria for the Guillain-Barre syndrome. The
disease usually begins from one to three weeks
after an infection, most frequently a respiratory
one. It may occur after one of the exanthemata,
but there is always an interval between the ex-
anthematous illness and the onset of the syndrome.
The disease occurs at all ages and in both sexes,
and the patient is ordinarily afebrile when ad-
mitted to the hospital. Dysesthesias of the feet or
hands, or both, usually precede the onset of
paralysis. Symmetrical weakness, usually of the
proximal muscles of the legs and often of the arms,
develops rapidly. On occasion, the distal muscles
are first involved. Severe involvement of the trunk
muscles is uncommon. The muscle weakness
spreads for some time, but it is unusual for it to
continue for more than two weeks. Objective sen-
sory loss is unusual, and characteristically it varies
even during a single day. The most common finding
is a fading “glove and stocking” hyperesthesia and
hypalgia. There may be transient difficulty in
voiding, but severe bladder involvement requiring
catheterization is not a part of the syndrome. Deep-
tendon reflexes are lost, or in mild cases are sym-
metrically reduced. Cranial nerves — most fre-
quently the seventh — are often involved on one or
both sides. It is thought that there is never an in-
volvement of either the optic or the auditory
nerves. Improvement begins about the third week,
and it continues without relapses. A spinal-fluid
cell count over 10 should raise a serious doubt
about the diagnosis, though a rise in protein is al-
ways present. A complete functional recovery,
without residuals, occurs in six months, and re-
covery is usually sufficient for discharge from the
hospital in three months. Reflexes may be reduced
for a long time. In rare instances, death occurs
early as a result of respiratory failure.

If the examination of the patient reveals other
abnormalities than those that have been described,
one should suspect some other form of polyneuritis
rather than Guillain-Barre syndrome. By using the
term “Guillain-Barre syndrome” loosely — by ap-
plying it to cases with much greater involvement
(the non-specific polyneuritides) — we can render it

308

Journal of Iowa Medical Society

May, 1962

meaningless. It should be reserved for the cases
that satisfy the criteria that have been enumerated.

1. Berlacher, F. J., and Abington, R. B.: ACTH and corti-
sone in Guillain-Barre syndrome: review of literature and
report of case following primary atypical pneumonia, ann.
int. med., 48:1106-1118, (May) ‘1958.

2. Osier, L. D., and Sidell, A. D.: Guillain-Barre syn-
drome: need for exact diagnostic criteria, new England j. med.,
2 62:964-969, (May 12) 1960.

Parental Guidance and Leadership

An article in a recent issue of look told the story
of a high school lad who had won a prize at the
National Science Fair by exhibiting a plasma jet
generator which he had built in his own home,
after many months of hard work and after many
disappointments. Much of the credit for the boy’s
accomplishment was given to his mother, who had
reared her family on the premise that “occupation
is dedication.”

While on a trip west, this writer recently heard
a prominent physician make a similar tribute to
his home and to his parents. The doctor spoke with
eloquence and reverence of his mother and father.
He was one of 14 children brought up in a home
where discipline was firm but affection was warm,
where industry was gospel, and where scientific
inquiry and the pursuit of knowledge were en-
couraged and guided. Of the 14 children, all earned
college degrees, and most of them went on to take
advanced training. Two of the boys have become
physicians and have made notable contributions to
medicine. The father left only a negligible estate,
but he had considered himself rich beyond meas-
ure.

One of the handicaps of modern America is the
lack of “chores” for youths in the average home.
But through the exercise of imagination and in-
genuity, the wise parent can find substitutes for
the wood chopping, milking, and comparable duties
which were assigned to earlier generations of
youngsters. Somehow, youths must learn the re-
wards of a difficult task well done, and must learn
the disappointments that attend a poor perform-
ance. The busy, happy lad is rarely a problem
child.

Well-educated and intellectually-inclined parents
today can give their children more than the man-
ual skills and the respect for work and thrift that
old-fashioned chores inculcated. Scientific curiosity,
and an impetus to pursue knowledge and to utilize
intellectual capacity wisely come in most instances
from parental inspiration, direction and example.
The responsibility cannot be left to the school. In
counseling parents, the physician and the teacher
can contribute generously to the welfare of youth
by urging parental participation in the intellectual
activities of their children — in helping them find
satisfaction in serious mental effort as well as in
strenuous physical activity.

Unfortunately, too many fathers seem to dodge
this responsibility, and later express disappoint-

ment over their child’s failure to utilize his talents.
Parental inspiration, guidance and example must
be provided consistently, starting in the young-
ster’s early childhood, if they are to be effective.
Erratic efforts by confused parents are self-defeat-
ing. Undue pressures and the setting of too high
standards of performance can do irreparable harm.
Expectations which exceed the intellectual capacity
or degree of maturity of the son or daughter will
be frustrating to both parent and child.

Learning should be pleasant and rewarding, and
it should be tempered with deep affection.

Corrections

In the panel discussion on the drinking and
driving problem that we published in the March,
1962, journal, we made some mistakes in repro-
ducing the statements made by Horace E. Camp-
bell, M.D., of Denver.

The sentences that conclude the paragraph at
the top of the right-hand column on page 110
should have read: “What is .15 per cent blood
alcohol? Of course it is exactly three times .05 per
cent, but in order to acquire it a man probably
has had to consume more than six ounces of 100-
proof whiskey or eight ounces of the 80-proof stuff.
He may have had to consume eight ounces of 100-
proof liquor, for there will have been a certain
amount of oxidation in the liver and alcohol-loss
by breathing.”

The final sentences of the next-to-last paragraph
in the left-hand column on page 111 should have
read: “For example, blood alcohol is tested on
the body of everyone who has died within six
hours of an automobile crash in the State of Mary-
land. The results show that 69 per cent of those
individuals had been drinking, and 40 per cent of
all those tested — not 40 per cent just of those who
had been drinking, but 40 per cent of all drivers
involved in fatal accidents — have had blood-alco-
hol percentages of .15 or more.

Then, the last sentence in the first whole para-
graph at the top of the second column on page 111
should have read: “The findings in that state, as
I have said, are that 69 per cent of drivers involved
in fatal accidents had been drinking, and that 40
per cent of them had blood-alcohol percentages
of .15 or more.”

Orchitis and Infectious Mononucleosis

Infectious mononucleosis is a disease of unknown
etiology which occurs frequently in the younger
age groups and is characterized by protean symp-
toms. Complications involving almost every organ
of the body have been described, from encephalitis
to interstitial nephritis.

A recent report by Wolnisty* described a new

*Wolnisty, C.: Orchitis as complication of infectious

mononucleosis: report of case, new England j. med., 2 66:88,
(Jan. 11) 1962.

Vol. LII, No. 5

Journal of Iowa Medical Society

309

complication of the disease — an acute orchitis in a
16-year-old boy. The patient was referred to the
hospital with a diagnosis of acute orchitis, atrib-
utable to epidemic parotitis. The history revealed
that the patient had had mumps at four years of
age. Physical examination and laboratory studies
established a diagnosis of infectious mononucleosis.

Knowledge that orchitis does occur as a com-
plication of infectious mononucleosis may save the
physician and the patient considerable anxiety, and
perhaps may spare the physician a measure of em-
barrassment.

AMA Urges School Health Exams

The AMA’s continuing support of periodic health
examinations for school children enters a new and
challenging phase with the recent announcement
that it will give full cooperation in implementing
a nationwide school health examination campaign.
The project is a vital part of the program spon-
sored by the President’s Council on Youth Fitness,
which was formed in 1959 under former President
Eisenhower and is being continued under Presi-
dent Kennedy. Charles B. Wilkinson, football coach
at the University of Oklahoma, heads the Council.

The AMA is urging every medical society to
start these examinations, if they are not already
routine in their respective communities. Letters
were sent to all component societies by AMA pres-
ident Leonard W. Larson, M.D., alerting them to
the program and urging them to cooperate with
school authorities and other interested groups in
setting up locally acceptable procedures for student
health exams.

Dr. Larson said, “Physical fitness must rest upon
firm foundations of health. Medical leadership is
essential in assuring these basic foundations. One
of the key factors in the process is the arrangement
of periodic medical examinations for youths of
school age which may best be given by the family
physician. Such examinations are an important
phase of preventive medicine, but also serve a
valuable function in classification of youths for
participation in physical activity.”

Enclosed with the letters to medical societies
were suggested procedures developed by the Na-
tional Committee on School Health Policies, which
will help guide societies in developing examination
programs at the local level. It is recommended, for
example, that school children be given a minimum
of four periodic medical exams during their school
years — at the time of entrance to school, during
the intermediate grades, at the beginning of ado-
lescence, and before leaving school. They should
be comprehensive, and informative enough to
“guide school personnel in proper counseling of
the student, and sufficiently personalized to pro-
vide a desirable educational experience.”

In setting up a health examination program for
students, it is suggested first that the project be
assigned to the school health committee or other

appropriate group in the local medical society, and
that a meeting be arranged between that commit-
tee and the school authorities and local health de-
partment personnel, to survey present arrange-
ments for periodic exams. Decisions must then be
made on a variety of questions such as where ex-
aminations shall be given — at the family physi-
cian’s office, at the school, or elsewhere — who shall
examine indigent children and those without fam-
ily physicians, what kinds of records shall be kept
of the examination findings, and how recommenda-
tions are to be interpreted to parents and to school
personnel.

Specific suggestions for dealing with these and
other questions are outlined in two publications,
“Health Appraisal of School Children” and “Sug-
gested School Health Policies,” which are being
forwarded by the AMA to all local medical soci-
eties.

The AMA's New Department
of Medicine and Religion

“How to provide better health care for ‘the
whole man.’ That is the chief concern of our new
department.” This is the Rev. Dr. Paul B. Mc-
Cleave’s nutshell definition of the American Med-
ical Association’s new Department of Medicine
and Religion which he heads.

The department was opened last September
with the goal of encouraging closer relationships
between physicians and clergymen in patient care.
“Too often today,” Dr. McCleave says, “we forget
to consider ‘the whole man.’ We forget the patient
and parishoner’s needs in total health — physical,
mental and spiritual. The three are not separable.”
Dr. McCleave feels that the best patient care is
achieved when physicians and clergymen are able
to share mutual concern for the patient and when
each contributes his special talents to the problem
at hand.

Terminal illness, he points out, is an excellent
example of an area in which the clergy can be of
particular help to physicians.

The new department will foster close physician-
clergy relationships through programs carried out
on the local medical society level and tailored to
fit local needs. Dr. McCleave is currently working
with medical society leaders and physicians in
nine states where pilot programs will be launched.
These states, chosen as a representative cross-
section of the entire nation, are: Arizona, Georgia,
Iowa, Maryland, Montana, New York, Ohio, Texas
and Utah. In both the pilot programs and those
which will follow, the new department will work
through state, county and local medical societies
as a servicing and counseling department of the
AMA. Specifics of the programs will be determined
by local medical societies.

Another project of the new department will be
the creation — on the state level — of leadership
teams of physicians and clergymen, including psy-

310

Journal of Iowa Medical Society

May, 1962

chiatrists and hospital chaplains. Using theoretical
case studies, these teams will present programs
to various medical and religious gatherings show-
ing how teamwork can be utilized for better patient
care.

Dr. McCleave lists two other key functions of his
department:

— The encouragement of closer relations be-
tween pastors and physician members of their
churches to discuss health and spiritual programs.

— The preparation of articles and editorials for
the medical and religious press. Early articles will
seek to define the patient’s total health needs and
point up the philosophy of “the whole man.”

Dr. McCleave says his department also plans
close liaison with hospital chaplains, mental health
authorities and pastoral clinical training centers,
furnishing any assistance it can. Similar liaison
is planned in the area of medical, theological and
nursing school curriculums.

Dr. McCleave, an articulate, soft-spoken man
who bears an astonishing resemblance to U. S.
Astronaut John Glenn, was until a short time ago
pastor of the First Presbyterian Church in Boze-
man, Montana. In his varied career he has served
as president of the College of Emporia, Emporia,
Kan.; spent 44 months as a Navy chaplain, 27 of
them overseas; and has pursued graduate study at
the University of Geneva, Switzerland. His work
in Geneva centered around the ecumenical church,
a study of all branches of the Christian faith.

Eradication of Tuberculosis in Children*

EDITH M. LINCOLN, M.D.

A group of authorities in various fields of med-
icine met at Arden House, in Harriman, New York,
in November, 1959, at the joint invitation of the
United States Public Health Service and the Na-
tional Tuberculosis Association. The conferees
agreed that the elimination of tuberculosis as a
public health problem was a practical goal, but
recognized that this objective was not achievable
for the country as a whole within the immediate
future.

Therefore, recommendation was made for the
establishment of immediate goals. Two such goals
have been proposed — an active case rate by 1970
of not more than 10 per 100,000 population (the
case rate in 1950 was 80), and control of infection
in each community to the point where not more
than one per cent of children at age 14 react to
tuberculin. For children, the objective is for tuber-
culosis to become as uncommon as diphtheria or
smallpox.

CHEMOTHERAPy THE FIRST TOOL

The most important tool in attaining this objec-
tive is chemotherapy. The public health reason for

* Reprinted from archives of environmental health, Octo-
ber, 1961.

treating adults is to render them non-infectious.
In children, the suppression of contagion is not of
public health interest. Even where there is marked
roentgenographic evidence of primary tuberculosis,
a very small population of bacilli is usually found
in cultures from gastric lavage of children. Fur-
thermore, most children with primary tuberculosis
are free from symptoms, including cough. Isolation
may not, therefore, be necessary, and some health
departments permit a child with primary pulmo-
nary tuberculosis to attend school if he is free from
symptoms.

When possible, however, a child with newly dis-
covered primary pulmonary tuberculosis should
be admitted to a hospital for one or two days so
that cultures can be obtained from gastric lavage
or from bronchial secretions. As the rate of tuber-
culosis falls, this procedure will become more im-
portant as a means of identifying bacilli resistant
to the usual drugs. Prolonged hospitalization of
children may be traumatic.

The main purpose of administering isoniazid to
children with primary tuberculosis is to prevent
complications.

Isoniazid is the only antimicrobial agent that
prevents the development of complications. It is
inexpensive and easily administered, and it should
be given for at least one year in doses of 10 to 15
mg./Kg. of body weight.

The present trend in most parts of the world is
to use combined therapy — that is, paraminosalicylic
acid (PAS) with isoniazid. In uncomplicated pri-
mary tuberculosis, and for use in secondary pro-
phylaxis to prevent complications, there seems to
be no reason why isoniazid should not be given
alone.

Recent converters, very young children with
reactions to tuberculin, all children with roentgen-
ographic evidence of manifest primary tubercu-
losis, and children with complications of primary
tuberculosis or with chronic pulmonary tubercu-
losis should be given specific therapy.

TUBERCULIN TEST THE SECOND TOOL

The second and most important tool for eradicat-
ing tuberculosis in children is the tuberculin test.
The emphasis should be on the number of tubercu-
lin tests and, in children with previously negative
tests, on the frequency of their repetition.

The tuberculin test is extremely valuable in di-
agnosis, but is not infallible. A Mantoux test will
produce a skin reaction when tuberculous infection
is present, provided the testing material is fresh,
the test is properly administered and read, and the
individual tested is not moribund, convalescent
from measles, or receiving steroid therapy. How-
ever, some skin reactions to tuberculin may occur
in those who have never been infected with tuber-
cle bacilli. Sometimes such reactions can be recog-
nized as atypical. A Mantoux which is red but not

Vol. LII, No. 5

Journal of Iowa Medical Society

311

indurated is not called positive. Measurement of
the Mantoux is important. Less than 5 mm. in
diameter is definitely negative, and 10 mm. or more
is positive. Between 5 and 10 mm., there is inde-
cision and the test should be repeated with the
same or a slightly larger dose. A test with 5 TU
of PPD (the intermediate strength) should select
99 per cent of positive reactors.

Another tool for the eradication of tuberculosis
is roentgenography. In children this tool should
never be used for surveys, but every child with
a positive tuberculin test should have a roentgeno-
gram. If the child has obvious tuberculosis, suffi-
cient films should be taken to guide the physician
in the care of the patient.

Other approaches to the prevention of infection
in children, aside from treatment and segregation
of infectious adults, are attempts to alter the re-
sistance of uninfected children by vaccination or
the use of isoniazid for primary prophylaxis. There
is no doubt that increased resistance to exogenous
infection can be obtained by vaccination, the BCG
strain of attenuated bovine bacilli being the agent
commonly used. This is of value in countries with
high incidences of tuberculosis, especially when
given to newborn children. From a public health
point of view, the artificial sensitivity produced by
BCG interferes with the use of the tuberculin test
in case finding. In areas of low morbidity, this is
a strong argument against the use of BCG.

ROLE OF THE PEDIATRICIAN

The prevention of tuberculous infection by the
administration of isoniazid has been proved in
experimental animals. The data from the prophy-
laxis study of the Public Health Service, when
published, should show whether or not this method
of prevention can be applied to human beings.

There are many contributions which the pedia-
trician can make to a tuberculosis control program.
First, the negativism about tuberculosis must be
overcome. Obviously, with a decreasing rate of
infection there will be less tuberculosis and fewer
tuberculin conversions. But the pediatrician must
continue aware of the possibility of tuberculosis.
Where there are tuberculous adults, there are in-
fected children. All children must be tested repeat-
edly in infancy and at least once a year ad infini-
tum or until conversion occurs. Prompt treatment
with isoniazid should follow conversions.

Tuberculosis is preeminently a social disease. It
increases where living conditions are poor and
homes overcrowded. Any measures to relieve pov-
erty and its attendant evils of inadequate nutri-
tion and crowding will help in the basic control
of the disease. The pediatrician must function not
only as a physician but also as a public-minded
citizen intent on securing for every child the right
to be protected from a preventable communicable
disease.

Iowa Medical Society Policy-Evaluation Committee Report

On the

National Blue Shield Senior Citizens Program

On January 15, 1962, the office of the Iowa Medi-
cal Society received information by telegram from
the AMA Board of Trustees relative to the Na-
tional Blue Shield Senior Citizens Program. The
AMA Board recommended that constituent medi-
cal societies take such action as is necessary to
cooperate with the proposed National Blue Shield
Program. The AMA Board felt that it could make
this recommendation on the basis of action taken
at the Minneapolis Interim Meeting in 1958 which
proposed that state medical societies cooperate
with sponsored Blue Shield Plans in the creation
of coverage designed to provide prepayment mech-
anisms for senior citizens at reduced premiums
and fee schedules.

On January 17, 1962, the IMS Executive Coun-
cil was apprised of the proposed National Blue
Shield Plan and by its action, President Otto

Glesne requested that the Policy-Evaluation Com-
mittee study the Program and present its recom-
mendations to the Executive Council and/or the
House of Delegates.

Not until late February or early March were
details of the National Blue Shield Plan received
locally. Immediately, work was begun by the staff
and the committee chairman in preparation for
a committee meeting. On March 21, the Committee
held an all-day session in Des Moines.

The provisions of the National Plan and the
Iowa Senior 65 Plan were compared and a num-
ber of questions or requests for interpretation
were drawn up. On April 2 and 3, Dr. John Mac-
Gregor, a committee member, and a member of
the IMS staff were in attendance at the Annual
Meeting of the National Association of Blue Shield
Plans in Colorado Springs. There the Iowa repre-

312

Journal of Iowa Medical Society

May, 1962

sentatives were able to obtain answers to some of
the questions raised by the Committee.

On April 5, the Policy Evaluation Committee
again met to hear the report of Dr. MacGregor.

Some of the important differences between the
national program and the Iowa Senior 65 Plan are:

1. In Iowa all contracts are single, and each in-
dividual must be 65 or over. The National Plan
will write single contracts for persons 65 and
over, and family contracts in which the subscriber
is 65 or over to include the spouse regardless of
age and all dependent children under 19 years of
age.

2. The Iowa service income limit is single —
$2,000 and couple — $3,000. The National Plan is
single — $2,500 and family — $4,000. In addition,
Iowa has a net worth clause of single — $20,000
and couple — $30,000. The National Plan has no net
worth clause, and this seems to be true of the ma-
jority of present senior citizen programs in other
states.

3. The Iowa Plan provides medical care in hos-
pitals up to 30 days. The National Plan provides
this care for 70 days, with an additional 13 weeks
—twice a week visits — for individuals who go di-
rectly from a hospital to a nursing home.

4. The Iowa Plan provides for consultation cov-
erage, but such coverage is not provided in the
national program.

5. In Iowa the waiting period for known condi-
tions is 11 months, and in the national plan the
waiting period is 6 months.

These are the more important differences in
the two plans.

Similar coverage by both plans includes surgery,
anesthesia, diagnostic x-ray, radiation therapy,
laboratory by or under the supervision of a doc-
tor, and concurrent and intensive medical care —
all on a fee schedule.

Other points of interest are, briefly:

The Plan will be implemented at the local state
level. The Iowa Relative Value Fee Index can be
utilized at least for the first year and will be re-
lated to the National Professional Services Index
compiled by National Blue Shield.

Claims will be judged first at the local level by
the Blue Shield Claims Committee.

Eligibility for full service will be stamped on
the subscriber’s card, but it may be questioned
and reconciled between the physician and the
subscriber patient at the time of service and will
be reviewed annually. The premium funds will
be pooled on a national level, and all losses will
be shared proportionately by the participating in-
dividual plans.

From its inception in 1958, the Iowa Senior 65
Plan has been well-received by the public and
has proved to be fiscally sound. After a short
period of experiment, the unit value for this pro-
gram was increased. A total of 7,100 individual
contracts are now in force, and it is estimated that

12,000 National Blue Shield contracts would be
the maximum number that could be sold in Iowa.

Some problems do exist at the time of this re-
port. The Iowa Senior 65 Blue Shield contract has
been sold as a package with the Iowa Blue Cross
Senior 65 policy. No open enrollment has been of-
fered recently by Iowa Blue Cross because its
policy has been proved fiscally unsound. To date
no National Senior Citizen Blue Cross Plan is
available to be sold as a package with the Na-
tional Blue Shield program. However, efforts are
being made by Blue Cross to formulate such a
plan, and at any early date it may be announced.
It is perhaps more difficult to develop a National
Blue Cross Plan which can be fiscally sound and
still set a premium level which will make it at-
tractive.

After a necessarily hurried but careful study
of the National Blue Shield program, the Iowa
Medical Society’s Policy-Evaluation Committee
voted to “approve the National Blue Shield Sen-
ior Citizen Plan and recommend that the Iowa
Medical Society’s House of Delegates endorse such
a Plan.” To date many local Blue Shield Plans
and state medical societies have approved the
national program. The neighboring states of Illi-
nois, Nebraska and South Dakota are among that
number.

A report embodying the foregoing facts will be
presented to the House of Delegates.

TELEPHONE SERVICE

Whiie you arc attending the
IMS Annual Meeting at the
Veterans Auditorium in Des
Moines, May 13-16, your of-
fice nurse can reach you by
calling

Des Moines
215-243-0344

President of Student AMA Chapter at Iowa City
Tells Why Medical Students Oppose
King-Anderson Bill

Extension of the remarks of the Honorable Fred
Schwengel of Iowa in the House of Representa-
tives, Thursday, March 15, 1962, from the Congres-
sional Record of Thursday, March 15, 1962.

Mr. Schwengel: “Mr. Speaker, in view of the big
push which is going to be made for a program of
medical care for the aged under Social Security, I
feel that it is pertinent to call attention to the
views of one of my constituents. This is a state-
ment from a young doctor-to-be, Mr. William K.
Hummer, president of the Iowa Chapter of the
Student American Medical Association. Mr. Hum-
mer has set forth a detailed analysis of the prob-
lem, and an appraisal of the current efforts to meet
this problem. I think that his comments are sig-
nificant and will be appreciated by all who are
concerned about this issue.”

March 1, 1962
Iowa City, la.

The Honorable Fred Schwengel
House Office Building
Washington, D. C.

Dear Representative Schwengel:

In my capacity, as president of the Iowa Chapter
of the Student American Medical Association, I
represent the great majority of the medical stu-
dents in the College of Medicine.

We have been closely watching the action which

is being taken on the King-Anderson bill (HR
4222). We feel that since we are the youngest seg-
ment of the medical profession, the outcome of this
proposal concerns us more than any others in our
field. We have attempted to study the background
and nature of this bill in order that we might reach
a logical and intelligent decision on its worth. We,
as students, felt that this was the only fair way to
arrive at a satisfactory conclusion. The following
comments represent the culmination of these
studies:

Basically, in considering any piece of legislation,
two things must be considered. First, is there a
need for this type of legislation? Second, what
method will provide the most effective way of car-
rying out the needed legislation? We have con-
cluded that there is no need for the specific type of
program embodied in the King-Anderson bill. In
addition, we feel that the method which has been
proposed to finance it will prove to be inflationary
and excessively costly.

There are approximately 17 million people in
this country over the age of 65. The King-Anderson
bill would cover approximately 13 million of this
group. Many of these who could be covered could
readily afford to pay for their own medical care.
Moreover, many of those not covered could not
afford to pay for such care. We do not believe that
there ever could be a need for a law that would
encompass so evident a degree of inequity.

One-half of the people over 65 already have

some form of health insurance. Recent statistics
show that people over the age of 65 are buying
health insurance at a rate four times greater than
all other age groups combined. Thus, private insur-
ance companies are proving themselves capable
of providing adequate, low-cost health insurance
to those over 65. These very figures defy the need
for government intervention in the field of health
insurance.

And finally, and probably most important, there
is no need for a law to provide medical care to the
aged since we already have such a program in
effect today. The Kerr-Mills bill was passed in the
last days of the Eisenhower administration. This
provides medical care for the aged through a pro-
gram of matching Federal and State funds and is
administered locally. It seems unnecessary to have
another law to provide medical care for the aged,
when this law has not even had a chance to prove
its effectiveness.

We feel it is evident that there is no need for the
King-Anderson bill. And, upon closer study of the
bill itself, it is clear that even if there were a need,
King-Anderson would not be the best means to
fulfill it.

Many Americans have been led to believe that
Social Security is a “tried and tested” insurance
program. This is a gross misrepresentation. In the
Supreme Court decision in the case of Fleming
versus Nestor (363 US, 609, 1960), the Court ruled
that “Social Security must be viewed as a welfare
instrument to which the legal concepts of insur-
ance, property, vested right, annuities, etc., can
only be applied at serious distortion of language.”

The financial status of Social Security as it exists
today is also open to question. In 1956 the benefits
owed those on OASI was 486 billion dollars. The
amount they would pay in was 194 billion dollars,
and the trust fund was 23 billion dollars. Thus,
there was a debt of 486 billion dollars minus (194
plus 23), or 269 billion dollars. In 1958, this debt
was 289 billion dollars, and in 1960 the debt was
350 billion dollars. This debt, of course, has no real
standing, such as the national debt, because there
are no government bonds to pay it. But, if Social
Security promises are to be met, then it is a debt
just as real as the national debt. We submit that

the proposed addition of medical care to the aged
to a program already so financially overburdened
would be unwise. It would result in inflation and
tax increases in Social Security far greater than
those currently proposed.

We are aware that there are people who are
unable to finance at all, or in part, their medical
care. It is our opinion that these are the people
whom we must help. These are the proposals which
we feel will provide adequate and equitable med-
ical care to the people of this country who really
need it.

First, the Kerr-Mills bill should be given a
chance to prove itself. It is working out well in
most states where it is now in effect. Funds which
are provided by the Federal and State govern-
ments could be used to pay the premiums on
health insurance policies from private companies
which would cover this group.

Second, doctors who treat patients who are un-
able to pay could be given an income tax deduc-
tion for each such patient treated. Physicians
throughout the country today willingly and hap-
pily treat thousands of patients for little or no
consideration. If, in the future, some income tax
deduction to doctors for these patients could be
allowed, these doctors would receive at least a
small recompense and the patients would have, in
effect, “paid” for their care.

There comes a point in national affairs when cer-
tain issues turn into every individual’s responsi-
bility. So far as this question of government inter-
vention in medicine is concerned, we feel that this
point has been reached and passed. We have
studied and made the preceding recommendations
because we felt that we had to. We felt that the
time had come when we were obliged to voice our
opposition to existing proposals and to make spe-
cific recommendations of our own.

Sincerely yours,

William Kirby Hummer, President
Iowa Chapter Student American
Medical Association
933 River Street
Iowa City, Iowa

THE JOURNAL Kook Shelf

BOOKS RECEIVED

BASIC ANXIETY, by Walter J. Garre, M.D. (New York City,
The Philosophical Library, Inc., 1962. $5.00).

EARLY DETECTION AND DIAGNOSIS OF CANCER, by
Walter E. O’Donnell, M.D., Emerson Day, M.D., and Louis
Venet, M.D. (St. Louis, The C. V. Mosby Company, 1962.
$12.00).

RENAL BIOPSY: CLINICAL AND PATHOLOGICAL SIG-
NIFICANCE—A CIBA FOUNDATION SYMPOSIUM, ed. by
G. E. W . Wolstenholme, M.B., B.Ch., and Margaret P. Cam-
eron, M.A. (Boston, Little, Brown and Company, 1962.
$10.50).

INTERNAL MEDICINE IN WORLD WAR II, VOLUME I—
ACTIVITIES OF MEDICAL CONSULTANTS, ed. by Col.
John B. Coates, Jr., MC, and W. Paul Havens, Jr., M.D.
(Washington, Office of the Surgeon General, Department of
the Army, 1961.)

AN ATLAS OF HEAD AND NECK SURGERY, by John M.
Lore, Jr., M.D. (Philadelphia, W. B. Saunders Company,
1962. $25.00).

CLASSICS OF CARDIOLOGY, VOLS. I AND II, ed. by
Frederick A. Willius, M.D., and Thomas E. Keys, M.A.
(New York City, Dover Publications, Inc., 1962. $2.00
each) .

A TEXTBOOK OF OBSTETRICS, by Duncan E. Reid, M.D.
(Philadelphia, W. B. Saunders Company, 1962. $18.50).

CURRENT DIAGNOSIS AND TREATMENT, 1962, by Henry
Brainerd, M.D., Sheldon Margen, M.D., and Milton J.
Chatton, M.D. (Los Altos, California, Lange Medical Pub-
lications, 1962. $8.50).

BOOK REVIEWS

Thalassemia: A Survey of Some Aspects, by Robin M.

Bannerman, M.A., D.M., M.R.C.P. (New York City,

Grune & Stratton, Inc., 1961. $6.50) .

This monograph, another of the “Modern Medical
Monographs” edited by Irving S. Wright, M.D., was
awarded first prize in the third Modern Medical Mono-
graphs competition. It constitutes an excellent survey
of a number of the aspects of the thalassemias. The
author discusses the genetics and incidence of this in-
teresting hemoglobinopathy altogether adequately, and
his presentation of the clinical features is complete.
He also discusses the various interactions and variants
of this interesting anemia, and then goes on to take up
hemoglobin and iron metabolism and its disorders, in-
cluding a number of the hypochromic anemias as well
as pernicious anemia and lead poisoning. His final
chapter deals with theories regarding the pathogenesis
of the condition, and contains a few suggestions re-
garding the objectives for future investigations.

The book will prove very interesting to those who
are concerned with anemic conditions, and for others
it should serve primarily as a reference source. The
photomicrographs and the various diagrams and charts

are quite adequate, and help to clarify the discussion.
It is obvious that the author has made a thorough
study of the pertinent literature, for he cites 375 ref-
erences.— M. E. Alberts, M.D.

Halothane [Fluothane], by C. Ronald Stephen, M.D.,
and David M. Little, Jr., M.D. (Baltimore, Williams
& Wilkins Co., 1961. $6.00).

Fluothane, one of the newer volatile anesthetic
agents, has been in clinical use for five years. During
that period, several million fluothane anesthetics have
been given. This monograph of 12 chapters and 142
pages reviews its chemistry, physics, physiologic ef-
fects and clinical use. There is a brief chapter by Dr.

J. P. Payne, of London, on the current British usage of
fluothane, which differs in many respects from Ameri-
can practice.

The book is concise, well written and attractively
printed and bound. It can be highly recommended. —

K. Garth Huston, M.D.

Carcinoma of the Cervix, by John B. Graham, M.D.,

Luciano S. J. Sotto, M.D. and Frank P. Paloucek,

M.D. (Philadelphia, W. B. Saunders Company, 1962.

$14.00) .

This book meticulously and exhaustively covers the
subject of carcinoma of the cervix. The first portion
very completely outlines the overall problem of malig-
nant disease of the cervix, including frequency, etiol-
ogy and pathology, as well as the accepted methods
of diagnosis.

A great deal of stress is placed upon carcinoma in
situ — its recognition and management — and properly so.
The senior author was trained with the Meigs group
at Vincent Memorial, the gynecologic service of Mas-
sachusetts General Hospital where much of the pi-
oneer work was done in the recognition of that clin
ical entity.

An excellent resume of the prognosis of this disease,
based on clinical staging as well as on histologic ap-
pearance, is presented. The chapter on cytologic prog-
nosis describes very well the phenomena of radiation
response (RR) and sensitization response (SR) orig-
inally brought out by the Massachusetts General
group of gynecologists.

Management and therapy are very thoroughly cov-
ered from the standpoints of surgery, radiation ther-
apy and a combination of the two. It is to the au-
thors’ credit that despite their coming from an institu-

313

314

Journal of Iowa Medical Society

May, 1962

tion that has done much to popularize surgical ther-
apy for this disease, they haven’t overstressed that
mode of treatment. One is left with the impression
that the authors still believe, by and large, that ther-
apy for invasive carcinoma of the cervix is best car-
ried out in a relatively large medical center that is
completely and adequately equipped. Certainly anyone
who has seen much of this disease must agree with
them on that point.

This is a textbook which the medical students and
the generalist who sees only an occasional case of
carcinoma of the cervix will have little use for. How-
ever, in spite of the fact that some space has been
wasted on fundamental trivia, the radiologist or gyn-
ecologist who is handling any volume of such cases
will find it a most useful reference book. — C. W. Sei-
bert, M.D.

Hypertension — Recent Advances, the Second Hahne-
mann Symposium on Hypertensive Disease, ed. by
Albert N. Brest, M.D., and John H. Moyer , M.D.
(Philadelphia, Lea & Febiger, 1961. $12.00).

This book is divided into seven major sections, as
follows: (1) natural history of hypertension; (2)

etiological mechanisms; (3) atherosclerosis and hyper-
tension; (4) pharmacology of hypertension; (5) cate-
cholamine metabolism; (6) drugs which affect cate-
cholamine metabolism; and (7) therapeutic considera-
tions. All the presently known facts and theories re-
garding the natural history, etiology and pharmacol-
ogy of hypertension are reviewed. Numerous charts
and illustrations are helpful. There are 117 contribu-
tors to this text.

This is an extremely detailed book, and its emphasis
is on the newer treatments. The chapters on the role
of catecholamine inhibitors are particularly interest-
ing. Fourteen panel discussions summarize and em-
phasize the pertinent points. The book is recommend-
ed to all physicians — Herbert Shulman, M.D.

Medical Genetics 1958-1960, by Victor A. McKusick,

M.D. (St. Louis, The C. V. Mosby Company, 1961.

$14.50) .

This volume is an unusually fine reference on ge-
netics, offering a quick survey of both general and
specific topics. A cumulative index and paragraph
numbers make it easy to use. The bibliography is com-
plete. Not only are the new books summarized, but
the sections are arranged to include history, general
genetics, human genetics, methods, cytogenetics in
man, biochemical genetics and congenital malforma-
tions. Should one want to review publications relating
to one particular system such as the circulatory or
the hematopoietic, abstracts of the presentations that
appeared during these three years are readily avail-
able to him.

In the first paragraph of his preface, Dr. McKusick
explains how he happened to start assembling mate-
rials for his book: “In 1958 my colleagues and I under-
took a review of the medical genetics literature for
that calendar year, and have continued the reviews
since then. The reviews are based mainly on the ac-

tivities of a successful ‘journal club’ in which the
several contributors participated. During the period of
the review, the participants were medical students,
house officers, research fellows, or staff members, most
of them attached to the Division of Medical Genetics,
Department of Medicine, The Johns Hopkins Univer-
sity School of Medicine. The ‘journal club’ and the
reviews emanating from it have represented a highly
useful pedagogical device, and it is hoped the reviews
will be equally useful to others. As indicated by the
title, the reviews for 1958, 1959, and 1960, previously
published separately in the journal of chronic dis-
eases, are combined in this book. It is hoped that the
accumulation of annual reviews will prove a partial
substitute for a full textbook of medical genetics
(which many feel is badly needed, but few have the
time to undertake) and will supplement the available
textbooks in the fields of general genetics and human
genetics.”

Attempts of many sorts are being made to provide
the profession with time-saving ways of keeping in-
formed on the progress that is being made in research
and practice. This publication is a highly successful
result of that sort of effort. — Charles L. Burr, M.D.

Good-Bye, Doctor Roch, by Andre Soubiran, M.D.

(New York City, Doubleday & Company, Inc., 1961.

$4.50).

This novel has a fictitious public mental hospital in
France as its setting, it concerns the struggles of its
medical director to develop a modern and humane
treatment program, and it is told from the standpoint
of a perceptive, intelligent and healthy patient in the
hospital.

Except for minor and unimportant details, the story
could easily have concerned developments of recent
years in many public mental hospitals of the United
States.

The enlightened, determined and humane efforts of
Dr. Roch, the medical director, to improve the treat-
ment and living conditions, despite incompetent and
defeatist colleagues and attendants, bureaucratic in-
terference, public prejudice against the mentally ill,
and lack of funds, parallel the history of similar ef-
forts in this country.

The picture of overcrowding, stupidity, cruelty and
understaffing, and of the work of the exceptional staff
member and attendant in bettering those conditions,
parallels the original state of affairs and the develop-
ment of progressive measures of care and treatment
in public mental hospitals here in recent years.

The reader’s interest is well sustained by the story
of the redemptive power on the patient of his wife’s
love, faith and support. The portrait of old Ferment,
the wise, gentle and devoted head attendant, is one
that will be familiar to anyone who has ever worked
in a public mental hospital.

Dr. Soubiran has succeeded very well in a task that
needed doing. I am confident that professionals and
all others interested in the problems of mental illness
will find this book most interesting and informative.
— Karl A. Catlin, M.D.

Credit and Collections

Credit is a convenience to which many people are
entitled. They are people with enough of either in-
come or willpower so that they don’t live beyond
their means and are always prompt in paying
what they owe. But for those who are either fi-
nancially insecure or weak-willed, credit is a
pathway to trouble.

When a patient first visits your office and fills
out a registration or information card, it is time
for you to discuss methods of payment with him,
so that you and he can arrive at a definite under-
standing. He will let you know whether he expects
to pay for each visit as he is seen, or whether he
prefers to pay for services at the end of each
month and has built up a record elsewhere that
justifies his being granted that privilege. He will
also tell you whether he has medical or sui'gical
insurance that will help him when large expendi-
tures are called for.

The only way in which you can help the patient
pay his bill is to make it easy for him to pay, and
we don’t mean by volunteering to extend credit.
Many patients prefer to pay as they are seen, and
this is most frequently true of those who are seen
only at long intervals. You can give a charge slip
for the call to the patient, listing the charges for
services and the total due for that visit, or you
can tell him the charge and give him an oppor-
tunity to pay, instead of just telling him it was
nice to see him or that you hope he will feel bet-
ter tomorrow.

Be sure to send statements promptly to the pa-
tients whom you have agreed to bill at the end
of the month. If you are late in sending the state-
ment, the patient is likely to lay it aside, planning
to pay it the next time he has occasion to write a
batch of checks, and before that time arrives an-
other month may have passed or he may have
forgotten or mislaid your statement. The majority
of payments on account are made within a week
after the end of a month or after the end of the
patient’s pay period. It therefore is important that
bills be sent by the first of each month, and if there
is no response, a second statement should be sent
at the end of the next month to serve as a re-
minder.

When the patient has ignored three monthly
statements, you should send a personal letter to
him. It should be short and simple, and you rather
than your physician employer should sign it. In
it, you can ask whether there is any question about

the account and whether there is a reason for his
not paying it.

If he still makes no response, send him a second
letter the following month, saying that you had
expected to hear from him and asking whether
some convenient arrangement can be made for
his paying the overdue account.

If he replies that he has had some unexpected
expenses that prevented his paying, but will take
care of the doctor’s bill within the next two weeks,
make a note of that promise on his ledger card,
and if the money hasn’t arrived at the end of the
designated period, send him a reminder saying
that you expect to hear from him shortly. Or if,
in his letter, he has said he will be unable to make
a payment for two or three months, note that
statement on his ledger card, and at the end of
that time ask him whether conditions have im-
proved and whether arrangements can now be
made for payment.

If six months have passed with no response to
statements or personal letters, then you should
send a final note stating that because you haven’t
heard from him his account will be turned over
to a professional collector within 10 days. Then
if he still fails to respond, turn the job over to a
collection agency. You have made every effort to
get the patient’s cooperation.

A neat, courteous letter can be a very effective
collection technic. It should always be addressed
to the person responsible for the account (with
his name spelled correctly), and should always
state the amount due. Make it personal and
friendly, and the response, in many cases, will
be friendly and prompt.

— Helen G. Hughes

315

THE DOCTOR'S BUSINESS

Your Health and Accident
Insurance Program

HOWARD D. BAKER
Waterloo

We are often confronted with the question:
“How much health and accident insurance should
I carry?”

In considering this matter, it is important for
us to remember that health and accident insurance
is disaster income, and that it is neither necessary
nor prudent for a man to carry insurance equal to
his earned income. On the contrary, it is necessary
only that he have adequate income during his
period of disability to provide the basic necessities
for himself and his family and to meet any fixed
obligations to which he is committed. It is much
more important for him to be sure of receiving in-
demnity for long enough periods, than to get an
over-generous amount for only a short time. Health
and accident insurance should be based on an ac-
cui'ate assessment of need, and should not be
carried in excess of that need or in the absence of
need.

After considerable study of the problem, we
have adopted the following basic principles regard-
ing health and accident programs:

1. Amount of Coverage. Monthly coverage
should consist of a minimum of $400 per month
plus $50 per month for each dependent, including
your wife, and plus an amount equal to the total of
your fixed monthly financial commitments. For ex-
ample, if you have a wife, three children and mort-
gage payments of $150 per month, you should carry
at least $750 monthly protection. In making this
computation, you should allow for whatever in-
come you have from sources other than your work
as a physician.

2. Types of Contracts. It is our recommendation
that at least 50 per cent of your coverage consist

of high quality, permanent, individual policies with
reputable companies. Needless to say, these should
be non-cancellable and guaranteed renewable to
age 65. Thus the permanence of at least one-half
of your program will be guaranteed.

After this portion has been secured, the remain-
ing 50 per cent should be made up of high grade
group contracts. These are semi-permanent, de-
pending upon the continuation of the group and of
your membership in that group. As a supplement
to permanent insurance, these contracts offer ex-
cellent coverage at very reasonable cost. Most
state medical societies and specialty groups offer
these quality group contracts today.

3. Indemnity Periods. Since we believe in long-
term catastrophic coverage, as opposed to short-
term protection, and since most doctors have cash
and accounts to carry them for at least 30 to 90
days, we recommend the following indemnity and
elimination periods:

a. Sickness. Indemnity should start the thirty-
first or sixty-first day, and shordd be payable for
a maximum period of seven to 10 years.

b. Accident. Indemnity should start with the
first day of disability, and should be payable for
life. Since most good policies pay from the first
day, no elimination period is recommended.

Health and accident insurance is a highly spec-
ulative field, and there are some bad as well as
many good contracts being written today. It should
be borne in mind that, as with most other goods
and services, you get what you pay for. On the
day you become disabled it will be too late to dis-
cover that the apparently “cheap” policy that you
purchased is virtually worthless.

With the aid of your insurance advisor, you
should carefully evaluate your needs and the pro-
visions of each contract before you buy.

316

Spring Postgraduate Conference
New Inn, Okoboji, Iowa
June 18-21, 1962

Once again the doctors of Iowa are invited to at-
tend the Iowa Chapter’s Spring Postgraduate Con-
ference at the New Inn, on Lake Okoboji. The lake,
reputed to be the second bluest in the world, is
sure to dispel whatever traces of a different sort
of blueness may have remained in the minds and
spirits of Academy members from the long, dreary
winter.

A sprightly course of lectures has again been
scheduled, and if this year is like last, physicians
will be enthusiastic about them, holding speakers
well past the lunch hour as they ply them with
questions.

Mornings are to be used for study, but the after-
noons and evenings will be spent in fun and frolic.
Bring your whole family to have a good time. You
can study in the mornings while your wife and
children sleep late. The many forms of entertain-
ment at Okoboji range from golfing to boating,
dancing, amusement-park rides, etc.

Write to the New Inn for your reservations.
Following is the scientific program:

Monday Morning, June 18

“Treatment of Cervical Lesions in Pregnancy” — Wm.
C. Keettel, M.D., Iowa City

“Influence of Host-Resistance Factors on Infectious
Diseases and Antibiotic Therapy” — R. S. Griffith,
M.D., Indianapolis

“Office Gynecology and Papanicolaou Smears”- — Ken-
neth R. Cross, M.D., Iowa City
“The Medical Therapy of Behavior Problems of Child-
hood”— John C. MacQueen, M.D., Iowa City
“Urinary Infections” — Wm. J. Martin, M.D., Rochester,
Minnesota

Tuesday Morning, June 19

“Hospital Procedures: Necessity for Controls and Ac-
curacy in the Laboratory”- — Dr. Cross
“The Treatment and Prognosis of the Seizure Patient”
— Dr. MacQueen

“Prophylaxis and Treatment of Staphylococcal Infec-
tions in the Hospital and Home” — Dr. Griffith
“Prevention and Management of Abortion” — Dr. Keet-
tel

“Bacteremic Shock” — Dr. Martin

Wednesday Morning , June 20

“Psychosomatic Aspects of Dermatology” — Francis W.
Lynch, M.D., Minneapolis

“The Diagnosis and Treatment of Certain Anorectal
Lesions” — Raymond J. Jackman, M.D., Rochester,
Minnesota

“Fungus Infections and Pediatric Dermatology” — Dr.
Lynch

“Ulcers of the Anus and Rectum” — Dr. Jackman
“Philosophical Aspects of Iowa Medicine” — Dwight G.
Sattler, M.D., Kalona

Thursday Morning, June 21
Heart Day

Sponsored by the Northwestern Iowa Heart Council
and Eli Lilly & Company’s Road Show Program

“Misdiagnosis of Rheumatic Fever” — Francis Fitz-
maurice, M.D., Creighton University School of Med-
icine, Omaha

“Coronary Angiocardiography” — Richard Booth, M.D.,
Creighton University School of Medicine, Omaha
“Clinical Diagnosis of Congenital Heart Disease” — Dr.
Fitzmaurice

“Laboratory Diagnosis of Heart Disease” — Dr. Booth

Symposium at Ft. Madison

There will be an afternoon and evening sym-
posium at the Golf and Country Club in Ft. Mad-
ison on Wednesday, May 23, sponsored by the Lee
County Medical Society and the Iowa Chapter of
the American Academy of General Practice.

Keep the date in mind. The program will be dis-
tributed by direct mail early in May.

Urge your patients to come,
and come, yourself, to the

AMA REGIONAL CONFERENCE ON
RURAL HEALTH
Savery Hotel, Des Moines
May 18-19, 1962

(The complete program appeared on the
“green sheet” in the April ims journal)

317

STATE DEPARTMENT OF HEALTH

Morbidity Report for Month of

arch

, 1

962

1962

1961

Most Cases Reported

Disease

Mar.

Feb.

Mar.

From These Counties

Diphtheria

Scarlet fever

500

395

236

Iowa, Jefferson, John-

Typhoid fever

son, Polk

Smallpox

Measles 2,960

620

654

Appanoose, Dubuque,

Whooping cough

Polk, Scott

Black Hawk, Dubuque,

Brucellosis

Lyon

Scott

Chickenpox

315

303

928

Dubuque, Polk, Story

Meningococcic

meningitis

Mahaska, Polk

Mumps

304

259

788

Boone, Crawford, Polk

Poliomyelitis

Polk

Infectious

hepatitis

1 15

178

219

Boone, Floyd, Polk,

Rabies in animals

Scott, Woodbury
Dickinson, Jasper, Keo-

Malaria

kuk, Marshall

Psittacosis

Q fever

Tuberculosis

For the state

Syphilis

101

For the state

Gonorrhea

146

For the state

Histoplasmosis

Webster

Food intoxication

Story

Meningitis (type
unspecified )

Dubuque

Diphtheria carrier

Aseptic meningitis 0

Salmonellosis

Dubuque, Lyon, Wapello

Tetanus

Chancroid

Encephalitis (type
unspecified )

H. influenzal
meningitis

Polk

Amebiasis

Boone

Shigellosis

Wapello

Influenza

508 14,576

Howard

Recommendations for Poliomyelitis
Immunizations
Iowa — 1962

A. The Sabin Oral Monovalent Vaccine. Types
I and II of the Sabin oral monovalent vaccine were
licensed in the fall of 1961. Type III was licensed
late in March of this year. Now that all three types
have actually been licensed, plans for their use
have become more practical, even though we have
no assurance of the amounts of the different types
of the vaccine that may be available.

The Sabin vaccine lends itself to group use. It is
best used and most effective on a community basis.
The types need not be given in numerical order.
Because of the high frequency of outbreaks of
intestinal virus illnesses which usually begin in
July and continue through October, the Sabin oral
vaccine should not be given during those months.
The so-called wild viruses prevent the attenuated
Sabin viruses from establishing themselves in the
intestinal tract and producing antibodies. Thus,
any oral vaccine program should be completed by
the end of June. If, because of the necessary in-
terval between doses, only two types can be given
before July 1, and if type III is available, it would
be preferable to start with type I and follow with
type III as the second of the series, leaving type II
to be given after October. (During 1961, 57.1 per
cent of virus isolations nationally were type I;
1.4 per cent type II; and 41.5 per cent type III.)

Remember, the first booster for the Sabin oral
monovalent vaccine is a polyvalent booster to fol-
low a year after completion of the series of three
feedings.

B. The Salk Poliomyelitis Vaccination Sched-
ule for 1962.

The Basic Series. All persons under 50 years of
age should be immunized. The basic series con-
sists of three injections: the initial injection, the
second injection four to six weeks after the first,
and the third injection usually given seven months
after the second.

Babies. Research during the past two years has
shown that the vaccine may be started in babies
as young as two months of age. For babies whose
immunizations are started before six months of
age, the basic series should consist of the initial

318

Vol. LII, No. 5

Journal of Iowa Medical Society

319

injection, a second injection a month later, a third
injection about a month after the second, and a
fourth injection seven to 12 months after the third.

Booster Injections. It is definitely established
that a booster injection of the vaccine should be
given to all persons a year after the completion of
their basic series of immunizations.

Subsequent Boosters. Probably the best interval
is two years after the first booster. However, for
the present, it is advisable to give special boosters
to persons in areas where poliomyelitis is in high
incidence, to pregnant women, to children about
to enter school and to persons planning to travel
in areas where sanitation is known to be poor.

The emphasis on special needs for poliomyelitis
vaccine continues to be directed toward three
groups: children under five, breadwinners be-

tween 25 and 50, and “islands” of population in
which the percentage of immunized individuals is
much lower than it is for the general public. Spe-
cial attention is directed toward children under
five and breadwinners because those two groups,
nationally, are below 50 per cent immunized.

IOWA— 1961
POLIOMYELITIS CASES

County

Age

Sex

Date of
Onset

Number of
Injections
of Vaccine

Date of Last
Injection

Audubon

Paralytic — 10 Cases
F 9-20-61 4

6-15-59

Clinton

8-23-61

Clinton

8-27-61

Delaware

7-16-61

Des Moines

7-26-61

1958

Mahaska

7-29-61

1958

Monroe

8- 9-61

Story

1 1-29-61

Wapello

1 1

8- 6-61

3-4-57

Wapello**

8- 2-61

*Date of injections not established
** Death 10-16-61

Non Paralytic — 8 Cases
Black Hawk 21 F 8-14-61 4

1959

Black Hawk

8-1 1-61

7-24-59

Buena Vista

8-20-61

5-26-61

Buena Vista

3-20-61

Des Moines

8- 3-61

Kossuth

1 1

8-19-61

5-1 1-61

Monona

11-10-61

10-55

Scott

9-14-61

Iowa’s 1961 record, like its record for 1960, shows
that the chances of developing paralytic poliomy-
elitis for persons who have had the basic series of
Salk vaccine, with boosters at the recommended
intervals, are very small.

Although Coxsackie viruses of several types
were isolated in various Iowa communities, no
polio viruses were found in 1961. No specimens
for virus studies were obtained from any of the
18 cases diagnosed as poliomyelitis. There were
several reasons why none were secured. The 18
cases were scattered state-wide and over a period
from March through November. Furthermore, the
case reports usually reach the State Department
of Health after the period during which it is pos-
sible to obtain specimens. Without a state virus
laboratory, we are limited to a depot system for
specimen collection. These depots can be set up
only in larger cities with laboratories that can
prepare and store specimens for shipment to the
USPHS Communicable Disease Center Labora-
tories at Kansas City. On that basis, although
specimens were sent from the areas of Des Moines,
Fort Dodge, Spencer, Waterloo, Burlington and
Davenport, no polioviruses were obtained.

Perhaps when Iowa has its own virus laboratory,
more specimens can be examined from all areas of
the state.

1961

UNITED STATES POLIOMYELITIS CASES BY PARALYTIC
STATUS, AGE GROUP AND VACCINATION HISTORY
REPORTED ON POLIOMYELITIS SURVEILLANCE
UNIT FORMS

(Through February 17, 1962)

Age

Group

ses o

f Vaccine

Unk. Total

Per

Cent

0-4

202

346

36.9

5-9

200

21.3

10-14

1 1

108

1 1.5

15-19

5.9

20-29

1 15

12.3

30-39

8.5

40-

3.5

Total

476

152

1 19

937

100.0

Per Cent

52.7

7.5

9.7

16.8

13.2

100.0

1961*

POLIOVIRUS ISOLATIONS
REPORTED BY U. S. PUBLIC HEALTH SERVICE
(All States)

Type 1

Type II

Type III

Total

248

180

434

Per Cent

57.1

1.4

41.5

100.0

*From 1961 cases reported to Poliomyelitis Surveillance
Unit through February 17, 1962. (This information taken
from Communicable Disease Center Poliomyelitis Surveillance
Report No. 251. February 23, 1962.)

lumaMeJNeiifi

President's Annual Report

The Woman’s Auxiliary to the Iowa Medical
Society has been organized 33 years, and has
accomplished a great deal. It is difficult to evaluate
the visible progress that has taken place in just
one short year, because our inheritance from the
yesterdays had brought us high on the ladder of
achievement. I have enjoyed the privilege and
challenge of serving as president. Much of the
satisfaction has resulted from the enthusiastic co-
operation of the officers in executing our goals.
We have endeavored to assist our medical societies,
particularly in the field of legislation; we have
found that working together stimulates friendly
relations among physicians’ families; and we have
coordinated and helped with the activities of our
constituent Auxiliaries.

The theme of our national president, Mrs. Har-
lan English, “Speak Your Beliefs in Deeds” surely
has been carried out in the reports of the county
presidents and state committees that follow:

Annual Meeting: Planned the program and
many details. Members from 16 Auxiliaries in
Central Area provided table decorations, took
charge of registration, and served as hostesses in
hospitality room. Board of Directors invited as
brunch guests.

A.M.E.F.: Stationery and playing cards sold.
Memorials to physicians who passed away this year
and individual county contributions reached a total
of approximately $500.00.

bulletin Circulation: Subscriptions number 51.
Mahaska Auxiliary can boast “Every Member a
Subscriber.”

By-Laws: Complete revision of the By-Laws was
accomplished. I take great pride in this achieve-
ment.

Civil Defense: Several Auxiliaries presented
programs on shelters.

Community Service: Physicians’ wives are ac-
tively engaged in numerous services in their com-
munities. Auxiliary-sponsored projects are: (a)

Six Handicapped Craft Sales (Waterloo, Fort
Dodge, Spencer, Sioux City, Des Moines, Du-
buque). Total sales — $3,974.08. (b) Volunteer

Health Service Award: County contests, each of
which selected a lay woman who has made the
greatest local contribution in the health field, (c)
A.A.P.S. Essay Contest: High School students eli-
gible. Topic — “The Advantage of the American Free
Enterprise System Over Communism” or “Advan-
tage of Private Medical Care.” Judges select win-

ners. Iowa Medical Society presents check for
$100.00 to top winner, and checks for lesser
amounts to second and third, (d) Eye Screening:
Several Auxiliaries aid other organizations in pre-
school eye examinations, (e) Homemaker Service:
Polk County Auxiliary and Medical Society con-
tributed $2,000.00 toward the development of this
service, the first homemaker service in Iowa.

Finance: Prepared a budget for the year’s ex-
penditures. Board members are informed of their
individual allowances.

Health Careers: 51 clubs in high schools. One
Health Career Day held in Des Moines in October.
Excellent opportunity for recruitment of young
persons.

Health Education Loan Fund: Total Fund $13,-
250.00. Auxiliaries and members-at-large contrib-
ute 50c per member; Annual benefit dance at time
of annual meeting; Memorials to this fund at death
of a member. Seven student nurses received loans
this year amounting to $3,779.30. The Dubuque
Auxiliary gave a $500 scholarship to a student of
its choosing (very outstanding project for one
Auxiliary). We urge all county Auxiliaries to par-
ticipate in the state project. We believe a loan to a
worthy student interested in a health profession is
better than a scholarship. Fifty students have ben-
efited from H.E.L.F.

Historian: Compiles records of importance to
the State Auxiliary.

Legislation: Committee has worked constantly.
Whether we are a member of a small or large
Auxiliary, a member-at-large or merely are eligi-
ble to be one, we have received instruction and
literature directing us to make our individual
effort toward defeating King-Anderson Bill, H.R.
4222. The Ronald Reagan record was played nu-
merous times. Many letters and resolutions were
sent to President Kennedy and Congressmen op-
posing the passage of this bill.

Membership: Organized Auxiliaries number 41.
Dickinson, Marion and Scott Auxiliaries organized
during the past year. Membership, as of April 20,
1962, totalled 1,203, representing a gain of 42 mem-
bers over 1961.

Mental Health: Increase of interest in this sub-
ject. Special services given to patients in hospital
wards. Iowa Mental Health Authority furnished
1,000 “Milestones to Marriage” packets.

Program and Year Book: The second vice-presi-
dent, with aid of administrative secretary, assem-
bled information for Year Book. Each member re-
ceived a copy by September 15. National program
material was made available upon request.

320

Vol. LII, No. 5

Journal of Iowa Medical Society

321

Publications: auxiliary news editor encourages
Auxiliary activity and collects pertinent informa-
tion from the officers.

Rural Health: Slowly developing. We urge each
county Auxiliary to send representatives to the
AMA Regional Conference on Rural Health May
18-19, in Des Moines. Specific projects suggested in
“green sheet” distributed with April issue of aux-
iliary news.

Safety: Prepared monthly “Tips for Safety” for
auxiliary news.

Special Committees: Drugs were sent to Bang-
kok, Thailand, for leprosy relief. Medical books
were sent to the Christian Medical Society, Oak
Park, 111.

We are proud to cooperate with WA-SAMA at the
University of Iowa. The State Auxiliary contribut-
ed $125.00 toward a delegate’s expenses to the
WA-SAMA Fifth Annual Convention in Washing-
tion, D. C. We urge the WA-SAMA advisor to be-
come a member of Auxiliary.

Our Auxiliary enjoys an excellent relationship
with the Iowa Medical Society. We were privileged
to have both Dr. Otto Glesne, president, and Dr.
George Scanlon, chairman of the Advisory Com-
mittee, as speakers at meetings of the Board of
Directors. I was invited to speak to the Senior
Medical Students’ Seminar on the topic “Medi-
cine’s Counterpart — The Woman’s Auxiliary.” I
reported to the Executive Council about Auxiliary
representation at various health meetings.

The Iowa Medical Society assumes great finan-
cial responsibility for Auxiliary activities: (1)

Cost of printing auxiliary news in the journal
each month, and of 1,200 reprints for distribution
to Auxiliary members; (2) Stationery, and postage
for all mailings from the office to membership; (3)
Mileage for members attending Board meetings;
and (4) The salary and expenses of the adminis-
trative secretary, Mrs. Hazel Lammey. We appreci-
ate her genuine interest and willingness to serve
our Auxiliary.

District meetings scheduled in one area of the
state each year deserve special comment. Each
councilor plans one meeting in her area during her
term of office. Members from every county partici-
pate. Districts II, V, X, and XI in the Central Area,
held meetings this year.

This report would not be complete without men-
tioning my many wonderful experiences: Serving
as presidential delegate to the National Auxiliary
Convention in New York, June, 1961, and attend-
ing the National Conference for Presidents and
Presidents-elect in Chicago; Representing our
Auxiliary at the Iowa Pharmaceutical Auxiliary
Convention; Iowa Dental Auxiliary Convention;
Iowa Veterinary Association Auxiliary meeting;
meeting of the Iowa Farm Bureau Women; and
meeting of the Iowa Teachers Association.

This briefly summarizes Auxiliary activities. We
hope our endeavors have brought us to another
rung on the ladder of achievement.

—Mrs. B. F. Kilgore

IMS Woman's Auxiliary Welcomes
Large New Group

An immutable law of physics states, “For every
action, there is a reaction.” Under the stimulus and
threat that government bureaucracies may stifle
American medicine, the Woman’s Auxiliary to the
Scott County Medical Society, has been organized.
After spirited discussions, the Scott County doc-
tors’ wives, under the aegis of designated officials
from the Scott County Medical Society, accom-
plished the all-important task, aided by a task
force from the Woman’s Auxiliary to the Iowa
Medical Society (Mrs. A. C. Richmond, president-
elect; Mrs. J. G. McMillan, district councilor; and
Mrs. R. F. Nielsen, past state president) . The group
held its first official meeting at the Outing Club,
in Davenport, on March 8, 1962.

Nominating and Bylaws Committees were
formed, to report at the final organizational meet-
ing, March 15, 1962. At that second meeting, Mrs.
James (Lenor) Bishop was elected president; Mrs.
Willard (Winnie) Pheteplace, vice-president; and
Mrs. R. V. (Jean) Daut, recording secretary. Also
elected for 1962 were Mrs. Robert (Helen) Byrum,
corresponding secretary; Mrs. Edwin (Mary)
Motto, treasurer; and Mrs. Robert (Betty Jean)
McConnell, historian.

At this meeting Mrs. Nielsen officially welcomed
the neophyte organization into the larger group of
dedicated workers, the Iowa Medical Society Aux-
iliary. She pointed out the opportunities it affords
women to become educated in the field of politics,
to warn other citizens of the State of Iowa about
the dangers of “creeping socialism,” and to im-
prove medical public relations on a person-to-per-
son basis in every community.

Over 70 women were signed as charter members
of the organization. Davenport has the distinction
of having been the site of the first hospital in the
State of Iowa. It can never claim to have had the
first Woman’s Auxiliary, but with diligence and
effort from the doctors’ wives, it perhaps will even-
tually have the best.

Our chapeaus are off to our newest organiza-
tion—W elcome !

COUNTY AUXILIARIES

BUCHANAN

The Buchanan County Woman’s Auxiliary enter-
tained the county’s doctors at a “Doctors’ Day”
luncheon at the Hotel Pinicon, in Independence,
on April 6. Mrs. J. F. Loeck, Auxiliary president,
in welcoming the doctors and their wives, read two
poetic tributes to the medical profession. Dr. Nel-
son Hersey, president of the Buchanan County
Medical Society, spoke on the problems and chal-
lenges, both medical and political, that face doctors

322

Journal of Iowa Medical Society

May, 1962

today. A choral group from Jefferson High School
sang several selections.

Mrs. Roger White was in charge of table decora-
tions for the luncheon, and the other committee
members were Mrs. Richard Free, Mrs. J. H. Hege,
Mrs. Donald Ingham, Mrs. Selig Korson and Mrs.
Charles White.

LEE (NORTH)

The annual “Doctor’s Day” was observed and
enjoyed the morning of March 30 by the doctors
of the Fort Madison area. Coffee and delicious
home made sweet rolls were served in the Sacred
Heart Hospital dining room by the members of
the North Lee County Woman’s Medical Auxiliary.
The traditional red carnation boutonnieres were
pinned upon suit coat lapels, scrub gowns, lab
coats and other miscellaneous apparel, accompa-
nied by a hearty congratulatory handshake.

To carry out the “Doctor’s Day” theme, the
table was centered with a lovely arrangement of
red carnations and white daisies flanked by long
tapers in silver holders.

Good food, good companionship, good conversa-
tion and good feeling was enjoyed by all. A very
successful “Doctor’s Day” event.

MAHASKA COUNTY

A luncheon meeting of the Mahaska County
Medical Auxiliary was held at the Downing Hotel,
Oskaloosa, on Tuesday, March 13, at one o’clock.
Mrs. Kenneth Lemon presided at the business
meeting which followed.

Six dollars toward the AMEF fund was collected
from members present. It is hoped that others will
contribute later.

Mrs. Lemon urged that the members write their
Congressmen, telling of their disapproval of HR
4222, the King-Anderson Bill.

Plans were started for Doctor’s Day. Mrs. Lemon
arranged to get a proclamation in the newspaper
from the Chamber of Commerce. On the eve of
Doctor’s Day, the Auxiliary entertained the doc-
tors at a dinner at the Elmhurst Country Club.
Dr. and Mrs. Alberti presented the program,
showing and commenting upon slides of their trip
to Europe.

WAPELLO COUNTY

The Wapello County Medical Auxiliary met at
the home of Mrs. R. A. Hastings, in Ottumwa, on
March 13, with Mrs. K. R. Kingsbury and Mrs.
P. I. Ekart, as assistant hostesses.

Delegates to the City Industrial Planning meet-
ing were named, and Mrs. P. W. Scott reported on
plans for a field trip to Omaha that the Future
Nurses Club members are to take. Following Mrs.
D. G. Emanuel’s report from the City Health Com-
mittee, a decision was made to donate a piece of
equipment which the Home Nursing Service may
lend to families that need it. As a part of the health
program, two cancer films were shown.

The following officers were elected for 1962-
1963: president, Mrs. Richard A. Hastings; presi-
dent-elect, Mrs. Leland H. Prewitt; vice-president,
Mrs. Dennis G. Emanuel; secretary, Mrs. Robert
D. Dalager; treasurer, Mrs. Paul W. Scott.

The April 3 meeting of the Auxiliary was held
in the home of Mrs. L. H. Prewitt, with Mrs. H. R.
Wood and Mrs. D. W. Wetrich as assistant host-
esses. A report on the recent Ottumwa Industrial
Growth Committee meeting was given. The spon-
soring of another student nurse was discussed.
Contributions to AMEF and for the school band’s
trip to the Kiwanis Convention in Denver were
approved. Following the business meeting, the
Northwestern Bell Telephone Company presented
a film on interior decorating.

Announcement

A.M.E.F. has been combined with the American
Medical Research Foundation, to be called AMA-
ERF. This changeover for the Woman’s Auxiliary,
however, will not take place until July 1, 1962. In
the meantime, the Auxiliary’s project will still be
known as A.M.E.F.

Des Moines-Polk County Home
Care-Homemaker Program

The Polk County Medical Society’s Committee
on Aging, appointed in 1958, studied the various
problems of the aged, and, on March 25, 1960, rec-
ommended to the Council of the Society that $500
be contributed toward the establishment of a Home
Care-Homemaker service. At that time, the Society
requested the help of the Auxiliary in investigating
the possibility of establishing such a service.

A committee was appointed from the Medical
Auxiliary and a prolonged investigation was
carried on. It was found that virtually every health
and social work individual and group in Polk
County recognized the need for a homemaker
service and was anxious to cooperate in establish-
ing it and assuring its success.

During 1960 and 1961, various groups interested
in this project were brought together at the office
of the Council of Social Agencies. It was obvious
that the largest obstacle to overcome was the fi-
nancing of such a venture. Many suggestions were
made, but nothing definite was forthcoming. The
Polk County Medical Society had already donated
$500, the Polk County Heart Association had given
$500, and this past Christmas the Medical Aux-
iliary gave the proceeds from its Christmas card
project — a total of $1,570.00. Since it had been es-
timated that the cost per year for hiring one case-
worker and five full-time homemakers would be
approximately $25,000, it was obvious that funds
would have to be obtained from other sources.

In August, 1961, the Council of Social Agencies

Vol. LII, No. 5

Journal of Iowa Medical Society

323

found that it might be possible to obtain a grant
from the United States Public Health Service for
a three-year demonstration program. At the end
of that time the Home Care-Homemaker Service
could be expected to have proved itself and could
find local support. A budget was prepared and an
application submitted to the U.S.P.H.S. for $25,-
000 per year for three years. This planning and
the resulting prospectus entailed much study and
prodigious work on the part of Miss Alice Whipple,
executive secretary of the Council of Social Agen-
cies. The grant was approved, and as of February
1, 1962, Mrs. Frances Shambaugh, a well qualified
caseworker, was employed as the coordinator of
the Home Care-Homemaker Service.

The operation of the Home Care-Homemaker
Service will be under the direction of Dr. James
Speers, director and Dr. Julius Connor, assistant
director, of the City-County Health Department,
both of whom are trained physicians, and the
Council of Social Agencies. The director and the
assistant director of the City-County Health De-
partment will provide medical review, supervision
and administration of the medical and nursing as-
pects of the program, and will provide medical di-
rection to the Home Care-Homemaker Advisory
Committee. Also, they will be the liaison officers
between the project services and the individual
physicians.

Mrs. Shambaugh, the coordinator, has been
busy recruiting, training and hiring women as
homemakers. She will decide which families shall
be provided homemaker service, and she will make
sure the service is not overutilized in any instance.
She will see to it that each family gets the social
services that it needs, but she won’t provide the
services herself. They will be rendered, in all in-
stances, by workers attached to one or another of
the public or private agencies in the city. Her
further duties will include assigning and super-
vising homemakers, approving payments to them,
and collecting fees for their work.

The Council of Social Agencies Home Care-
Homemaker Advisory Committee, the chairman of
which is a medical Auxiliary member, will assume
responsibilities similar to those of a private wel-
fare agency board. It will consist of representatives
of 36 groups that need to participate in this project
to assure its development, acceptance and eventual
support as a locally-maintained welfare service
after the demonstration funds have expired. This
committee will set policies and act on monthly re-
ports from the medical director, the caseworker
and C..S.A. staff members. The groups represented
are:

Polk County Medical Society

Polk County Medical Auxiliary

Polk County Society of Osteopathic Physicians

Polk County Osteopathic Physicians Auxiliary

State Department of Health

Blue Cross-Blue Shield

Public Health Nursing Association

Division of Vocational Rehabilitation
Joint Committee on Health Care of Aging
Polk County Health Improvement Society
Younker Rehabilitation Hospital
Hospital Council
Broadlawns Hospital

Iowa Chapter, Arthritis and Rheumatism Founda-
tion

American Cancer Society

American Heart Association

Polk County Tuberculosis Association

Polk County Muscular Dystrophy Association

Polk County Multiple Sclerosis Society

Polk County Chapter, National Foundation

Polk County Retarded Children’s Association

Polk County Mental Health Association

Polk County Association for Crippled Children and

Adults

Goodwill Industries

Veterans Administration Center

Polk County Welfare Department

Polk County Board of Supervisors

Family Service-Travelers Aid

Catholic Charities

Iowa Children’s Home Society

Polk County Chapter, American Red Cross

United Community Services

Department of Adult Education, Des Moines Public

Schools

Iowa State Employment Service
Junior League
Polk County Labor Council
State Commission on Aging

Fees are to be collected from families according
to their ability to pay. When a family is receiving
monetary assistance from a social work agency, the
agency providing it will be charged approximately
the actual cost of homemaker service.

Iowa and some surrounding areas lack home
care-homemaker services. In order to extend bene-
fits provided Polk County through federal funds,
the Home Care-Homemaker Service Committee
will hold an annual institute to which interested
organizations and individuals throughout Iowa and
surrounding unserved areas will be invited. The
Adult Education Department of the Des Moines
Public Schools, the State Department of Health
and the health education director of the City-
County Health Department will assist the Commit-
tee in developing and publicizing the institute.

On March 14, 1962, the first class, 14 unusually
high-calibre women, completed the training course
for homemakers. They are enthusiastic and eager
to start the program. The course, under the Adult
Education Department, consisted of ten two-hour
sessions, extending over a five day period. It was
taught by members of the various groups of the
Advisory Committee. Subjects taught were primar-
ily the philosophy of working and being around
people who are ill, the meaning of illness in a
family, understanding the elderly, and family life
in relation to food. It was assumed, and correctly

324

Journal of Iowa Medical Society

May, 1962

so, that the women who would apply to take a
homemaker course would already possess the or-
dinary skills of homemaking.

On March 27, 1962, the first meeting of the Ad-
visory Committee was held, after which the Home
Care-Homemaker Service started operation.

It is to be noted that the Des Moines-Polk
County Home Care-Homemaker Service has been
established as the result of a community-wide ef-
fort, with both casework and medical supervision.
Because of its solid foundation and because of the
high enthusiasm of all interested groups, we are
practically assured of the success of this new and
long-awaited venture. The Polk County Medical
Auxiliary is happy to be a part of such an effiort.

- — Mrs. Allan Phillips

Chairman, Home Care-Homemaker
Committee, Polk County
Medical Auxiliary
Chairman, Advisory Committee of
Home Care-Homemaker Service,

Des Moines Council of
Social Agencies

Recreation Safety — Bicycles
Tips for Safe Biking

1. Remember — when you ride a bike, the traffic
lights, signs and laws are meant for you! Please
obey them.

2. Make sure your bike is licensed, if required by
law in your community.

3. Know hand signals and when to use them.

4. Walk your bike across busy streets and with-
in white lines at intersections.

5. Keep both hands on the handles at all times,
except when making signals.

6. Ride your bike on the sidewalk whenever
possible. It’s not allowed, however, in business or
congested areas.

7. If necessary, ride on the right side of the
street, close to the curb, and move with traffic.

8. Watch for parked cars turning out, and for
car doors opening.

9. Travel single file when riding in a group,
keeping a full bike length behind the preceding
bike.

10. Stop, look and listen before entering a street
from sidewalk, driveway or alley.

11. Don’t carry passengers or heavy bundles.

12. Check your bike out monthly on these
points: handle grips, saddle, wheels, reflectors,
brakes, chain, pedals, crank hangar, bell or horn,
handle bars, fork lights, spokes, tires, tire valves,

and rear view mirror. Also check for loose nuts,
bolts and screws.

POINTER FOR PARENTS

It’s up to you to lay down the law on dangerous •
bike stunts and traffic dodge games. But most of
all, your example of caution and courtesy behind
the wheel of the family car will strongly influence
your youngster’s biking habits.

Home Safety — Falls

1. Anchor all scatter rugs (use anti-skid or
liquid spray adhesive) .

2. Repair loose stair and porch railings.

3. Repair worn steps and stair treads (use non-
skid treads or sand mixed with paint on concrete
basement stairs).

4. Provide furnishings and bathroom fixtures
that are suitable for older persons (grab bars, bath
tub mats, bed rails and firm, high-seated chairs) .

5. Install window gratings or sturdy screens for
youngsters.

6. Keep backyard play equipment (swings,
slides, etc.) in good condition and properly bal-
anced.

7. Have swing gates at the top and bottom of
staircases for toddlers.

8. Clear floors immediately after spills, especially
water and grease.

9. Provide adequate lighting, located at the en-
trances to all rooms and at the top and bottom of
staircases.

10. Clear steps, driveways and sidewalks of ice
and snow as soon as possible.

11. Use ladders or step-stools for all climbing
chores, and keep them in good condition.

CADUCEUS CAPERS

Tuesday, May 15 — Banquet and Dance
Des Moines and Terrace Rooms — Hotel Savery

Benefit Dance for

Woman’s Auxiliary Health Educational Loan
Fund

Evan Morgan’s Orchestra

Standard Medical and Surgical Company
sponsor the social hour from 8:30

WOMAN’S AUXILIARY TO THE IOWA MEDICAL SOCIETY

President — Mrs. B. F. Kilgore, 5434 Woodland, Des Moines 12 Treasurer— Mrs. J. H. Matheson, 4321 California Drive, Des

President-Elect — Mrs. A. C. Richmond, 1132 Avenue A, Fort Moines 12

Madison Editor of the news — Mrs. Herbert Shulman, 101 Martin Road,

Recording Secretary — Mrs. F. L. Poepsel, West Point Waterloo

Corresponding Secretary — Mrs. N. W. Irving, Jr., 4916 Har-
wood Drive, Des Moines 12

¥TTI 1

\ '

' J T

I \

j L

ru .

orf 7/ij^

WCIETY

IN THIS ISSUE:

• Senator Hiclcenlooper on Current

Legislative Proposals Affecting
Medicine, page 325

• Surgical Emergencies in the Neonatal

Period, page 329

• Management of the Patient With
Headaches, page 337

Peripheral Arterial Occlusive Disease —
What Can the Surgeon Offer?,
page 342

Metronidazole, a New Trichomonacide,
page 346

Isolation of Histoplasma capsulatum
From Iowa Soil, page 348

— — ' .A £p..'.

U.C. MEDICAL CENTER LI DR ARY

JUN 1 1 1962

San Francisco, 22

sign of infection?

symbol of therapy!

Ilosone® is available in three convenient forms: Pulvules®— 125 and 250 mg.*; Oral
Suspension— 125 mg.* per 5-cc. teaspoonful; and Drops— 5 mg.* per drop, with
dropper calibrated at 25 and 50 mg.

This is a reminder advertisement. For adequate information for use, please consult manufacturer's literature. Eli Lilly and
Company, Indianapolis 6, Indiana. Ilosone® (erythromycin estolate, Lilly) *Bc,.se equivalent

Ilosone works to speed recovery

She?

“ crying solitary in lonely places ”

(diphenylhydantoin, Parke-Davis)

permits a richer life for the epileptic

“ It has been more than twenty years since the introduction of
diphenylhydantoin sodium (DILANTIN Sodium) as an anti-
convulsant substance. This drug marks a milestone in the
rational approach to the management of the epileptic.”1
In grand mal and psychomotor seizures , DILANTIN is a drug
of choice for a variety of reasons: • effective control of sei-
zures1'9 • oversedation is not a common problem2 • possesses
a wide margin of safety3 • low incidence of side effects3 • its use
is often accompanied by improved memory, intellectual per-
formance, and emotional stability.10 DILANTIN (diphenylhy-
dantoin, Parke-Davis ) is available in several forms, including
DILANTIN Sodium Kapseals,® 0.03 Gm. and 0.1 Gm., bottles
of 100 and 1,000. Other members of the PARKE-DAVIS FAMILY
OF ANTICONVULSANTS for grand mal and psychomotor sei-
zures: PHELANTIN® Kapseals (Dilantin 100 mg., phenobar-
bital 30 mg., desoxyephedrine hydrochloride 2.5 mg.), bottles
of 100. for the petit mal triad: MILONT1N® Kapseals (phen-
suximide, Parke-Davis) 0.5 Gm., bottles of 100 and 1,000;
Suspension, 250 mg. per 4 cc., 16-ounce bottles. CELONTIN®
Kapseals ( methsuximide, Parke-Davis ) 0.3 Gm., bottles of
100. ZARONTIN® Capsules (ethosuximide, Parke-Davis) 0.25
Gm., bottles of 100.

This advertisement is not intended to provide complete information for
use. Please refer to the package enclosure, medical brochure, or write for
detailed information on indications, dosage, and precautions.

REFERENCES: (1) Roseman, E.: Neurology 11 .912, 1961. (2) Bray, P. F.:
Pediatrics 23:151, 1959. (3) Chao, D. H.-, L truckman , R., & Kellaway, P.: Con-
vulsive Disorders of Children, Philadelphia, W. B. Saunders Company, 1958,
p. 120. (4) Crawley, J. If'.: M. Clin. North America 42:31 7, 1958. (5) Livingston,
S.: The Diagnosis and Treatment of Convulsive Disorders in Children, Springfield,
III., Charles C Thomas, 1954, p. 190. (6) Ibid.: Postgrad. Med. 20 .584, 1956.
(7) Merritt, H. H.: Brit. M. J. 1:666, 1958. (8) Carter, C. H.: Arch. Neurol. &
Psychiat. 79:136, 1958. (9) Thomas, M. H., in Green, J. R., & Steelman, H. F.:
Epileptic Seizures, Baltimore, The Williams & W ilkins Company, 1956, pp. 37-48.
(10) Goodman, L. $., & Gilman, A.: The Pharmaco-
logical Basis of Therapeutics, ed. 2, New York, The
Macmillan Company, 1955, p. 187. 92462

PARKE-DAVIS

PARKE. DAVIS A COMPANY. Detroit 32. Michigan

Vol. Lll

JUNE, 1962

No. 6

CONTENTS

Medical Legislation from the Standpoint of the
Legislator

Hon. Bourke B. Hickenlooper, Senior U. S.

Senator from Iowa 325

SCIENTIFIC ARTICLES

Surgical Emergencies in the Neonatal Period
Robert T. Soper, M.D., Iowa City .... 329

The Management of the Patient with Headaches
Adrian Ostfeld, M.D., Chicago, Illinois . 337

Peripheral Arterial Occlusive Disease: What Can
the Surgeon Offer?

Harold Laufman, Ph.D., M.D., Chicago, Illinois 342
Experience with Metronidazol, A New Tricho-
monacide

John E. Krettek, M.D., Council Bluffs 346

Isolation of Histoplasma capsulatum, Allescheria
boydii and Microsparum gypseum From Iowa
Soil in an Attempt to Determine the Probable
Point Source of a Case of Histoplasmosis

John Cazin, Ph.D., William F. McCulloch,
D.V.M., M.P.H. and John L. Braun, M.S., Iowa

City . 348

State University of Iowa College of Medicine
Clinical Pathologic Conference 352

EDITORIALS

Care in the Use of Terms 364

Villain or Hero 365

Self-Discipline 365

Abdominal Surgery in Geriatric Patients 366

Ulcerative Colitis in Children 366

Again, Carcinoma of the Breast 367

SPECIAL DEPARTMENTS

Coming Meetings 362

President’s Page 368

Case Studies: Micturition Syncope: Reports of

Two Cases

R. Overton, M.D., Des Moines 369

Hearing Conservation: Definition of a Hearing

Conservation Program 372

Mental Health: Program of the Woodward State
Hospital and School

W. C. Wildberger, M.D., Acting Superintendent 374

Journal Book Shelf 377

Iowa Chapter of the American Academy of Gen-
eral Practice 379

Iowa Association of Medical Assistants . 381

In the Public Interest facing page 382

The Doctor’s Business 383

State Department of Health 384

Woman’s Auxiliary News 386

The Month in Washington xxx

Personals xxxiii

Deaths xlv

MISCELLANEOUS

Nuclear Medicine to Be Major Topic at AMA

Annual Meeting in Chicago 328

Just Like a Doctor’s Prescription — Used to Be 341
S-R Foundation Starts Deluxe Preceptorships 351
Fumes Claim More Lives Than Do Flames . 378

No Wonder We’re Broke! 380

The Doctor’s ‘Revolt’ 382

English Mental Patients Will Be Moved to General

Hospitals xxxvii

Sadove Says Addicts Shouldn't Be Regarded as

Criminals xxxviii

Low-Back Pain xxxix

Measles Immunity May Not Depend on Re-expo-
sure xl

New Approach to Acne Therapy xl

Swine Replace Cattle as Brucellosis Soars xlii

Drug Treatment for Mental Patients .... xlviii

EDITORS

Dennis H. Kelly, Sr., M.D., Scientific Editor Des Moines

Edward W. Hamilton, Ph.D., Managing Editor

Des Moines

SCIENTIFIC EDITORIAL PANEL

Walter M. Kirkendall, M.D Iowa City

Floyd M. Burgeson, M.D Des Moines

Daniel A. Glomset, M.D Des Moines

Robert N. Larimer, M.D Sioux City

Daniel F. Crowley, M.D Des Moines

PUBLICATION COMMITTEE

Samuel P. Leinbach, M.D Belmond

Otis D. Wolfe, M.D Marshalltown

Cecil W. Seibert, M.D Waterloo

Richard F. Birge, M.D., Secretary Des Moines

Dennis H. Kelly, Sr., M.D., Editor Ex Officio Des Moines

Address all communications to the Editor of the Jour-
nal, 529-36th Street, Des Moines 12

Postmaster, send form 3579 to the above address.

Medical Legislation From the Standpoint

Of the Legislator

HON. BOURKE B. HICKENLOOPER
Senior U. S. Senator From Iowa

It is a pleasure indeed to be here today and visit
for a short time with the Iowa Medical Society in
its Annual Convention. It is also an appropriate
time to meet with the medical people of my state
because of the major legislation and discussion
affecting the relationship of your profession, the
government and the whole field of health care in
the nation.

You are familiar with the major provisions of
the legislation that is now before the committees
of Congress proposing limited benefits for the
aged under the Social Security system. There are
others with somewhat different approaches. Then
there is the Kerr-Mills bill already on the books
and being rapidly implemented in the states.

In 1960, we passed the Kerr-Mills law which
provided the framework for making available cer-
tain benefits to approximately 10 million persons
over 65 years of age who could meet the eligibil-
ity requirements. As you know, one of the main
provisions of this plan was that each state could
formulate its own eligibility standards, which,
under our system of government, is in harmony
with the fundamental belief that the states had a
responsibility to adapt such programs, which pri-
marily concerned themselves, to internal condi-
tions within the state.

Incidentally, in the event that you may have
forgotten, Senator Anderson and the then Senator
Kennedy proposed at that time an amendment to
attach the Kerr-Mills program to Social Security.
Fortunately this approach was defeated.

PRESENT PROPOSALS

We now have before the Congress an Admin-
istration bill which ties medical assistance to
Social Security. This bill is confusing and de-
ceptive. It penalizes those who have provided for
their old age and can take care of their own medi-
cal care, to favor those who have not. It fails to
emphasize need, but it would be a large foot in
the door for opening the entire field of medical
care to the bureaucrats.

Senator Hickenlooper gave this address at the Annual Meet-
ing of the Iowa Medical Society, in Des Moines, on May 15,
1962.

Today the United States, under a private system
supplemented by public contribution in case of
proved need, has the best medical care of any na-
tion in the world. We long have had effective self-
help medical plans in keeping with the American
tradition of personal responsibility. Where mis-
fortune intervenes, local programs and financing,
in cooperation with our doctors, normally provide
the necessary care and service. In practice, the
aged person not getting adequate medical care is
the exception, and it is not because such needed
care is unavailable. I do not think legislation such
as that proposed is necessary. I believe we should
stay with successful privately-financed plans and
existing law.

Apparently others agree with me. A distin-
guished gentleman from California has said blunt-
ly of free hospitalization proposed for a segment
of the aged, “We can’t afford it.” In freeman mag-
azine for June, 1960, he said that such extension
of free aid “is bound to be merely the first step
to an enormously expanded and still more ex-
pensive Federal health care program.” He added
that, by itself, this program would either add
greatly to our taxes or make inadequate our
available funds for Social Security. This man? He
is today the Postmaster General of the United
States, a member of the Kennedy Cabinet, the
Honorable J. Edward Day.

The busy propagandists who want to use the
appeal of public health to expand political bu-
reaucratic control try to create the impression
that opposition to them and their program is al-
most like being against God, Mother, and Home.
The fact of the matter is, however, that much of
this legislation will provide — not needed benefits
to the aged — but income and salaries to the bu-
reaucrats who operate under Parkinson’s law,
and who are inclined to increase the Table of
Operations to utilize all available funds which
can possibly be earmarked for administration. I
sincerely hope you doctors do not end with a
bureaucratic “big brother” at each elbow advising
on an operation. Seriously, it seems apparent that
much of the drive behind this politically-con-
ceived and inadequate plan is nothing but the
bureaucratic urge for greater political power, re-
gardless of cost or effect. We have all heard about
“lies and statistics.” Self-serving statistics have
been issued by this Administration — which “in the

325

326

Journal of Iowa Medical Society

June, 1962

wink of any eye” can change a horse chestnut
into a chestnut horse — thus falsely “proving” that
the country is veritably populated by individuals
who in mortal pain are residing in hovels without
the benefit of medicine, or a physician’s care.

A huge lobby has been established in Washing-
ton called by the high-sounding name of the Na-
tional Council of Senior Citizens for Health Care
Through Social Security. Its offices are plush; its
money — apparently unlimited. It publishes a bul-
letin entitled “Our Responsibility to Our Parents”
— and then, in an amazing bit of forensic leger-
demain, advocates that we all abdicate our re-
sponsibility to our parents to some Uncle named
SAM. The astute reporters of the new york herald
tribune however have been able to trace its man-
agement and direction — the path leads right into
the very offices of the White House.

Despite its high-sounding name, this organiza-
tion is nothing but a political lobby aimed at ex-
ploiting the fears of some elderly people in at-
tempt to corral the votes of all our senior citizens.

FOREIGN EXPERIENCE IN FEDERALLY DOMINATED
HEALTH PLANS

Many years ago Patrick Henry told the people
of Virginia in one of his famous orations, “I have
but one lamp by which my feet are guided, and
that is the lamp of experience.”

It is surprising to me that some responsible peo-
ple in this country may be deluded into advocat-
ing programs which have been tried in many
parts of the world and which, without exception,
have ended either in dismal failure or excessive
public cost and, moreover, have reduced the pro-
ficiency of the medical profession and its service
to the public.

In France, government budgets for national
health services have been strained so that funds
are not available for research; the health services
provided have required a special tax of 6 per cent
on employees and 29 per cent on employers, and
the schedule of benefits has exhausted assets.

In West Germany, the availability of state medi-
cal services seems to promote abuses in the de-
mand for them. Companies employing 5,000 per-
sons as a practical routine apply for 5,000 sick-
ness certificates a quarter, for they know that al-
most every employee will find it convenient to
report sick at least once in the quarter. The cost
of drugs in France has increased over 50 per cent
in six years, whereas in the United States, under
our private system, the increase has been only 37
per cent in 23 years.

In Australia, such a load of work has fallen
upon the “socialized doctor” and his service to the
needy patient has so deteriorated, that demand
for the private doctor is rapidly increasing. In-
creasing numbers of people are willing to pay for
and demand private medical services, despite the
heavy taxes for socailized medicine. Australian

doctors are compelled to depend upon the medical
research of the United States because of the
breakdown of research under socialized medicine.

In Japan, a member of the Japanese Doctors
Association, Dr. Akira Osada, has urged the United
States to continue opposing socialized medicine.
In Japan the income of physicians is recognized j
to be in one of the lowest brackets in the medical
world, with salaries to doctors ranging from 50
cents per office call to $41 for difficult lung sur-
gery. No wonder that under such a line production
operation they “paint them with idodine and
mark them ‘duty.’ ”

In England, the doctor is subordinate to the
bureaucrat, and the art and science of medicine
is reduced to an instrument of politics. The cost
of the British health program, passed by the
Labor party after World War II, turned out to be
three times the “promised” figures. It now costs 1
$2.5 billion a year, and even its supporters admit
that its service is grossly inadequate. With govern-
ment medicine, the British built only one hospital
in the entire British Isles during the ten-year '
period 1948-1958. In the United States, under our
private medical system and local responsibility !
for health care 658 new hospitals were built dur-
ing the nine-year period 1948-1957.

In the State of Colorado, a constitutional amend-
ment was passed in 1956 to finance a health and
medical care program for aged persons who re- |
ceive state pensions. Because of glowing propa-
ganda about it, affected citizens of Colorado re- ;
sponded so enthusiastically that current costs of
the program almost double the 1958 cost of $5.7
million. State officials have now scaled down the
widely-heralded experiment, cutting hospital stays
to 18 days, limiting nursing-home care to the very
feeble, and letting the aged enter hospitals only
in emergencies. Free ambulance rides have had
to be abolished.

The Chicago tribune has said, “Colorado’s fail-
ure, with a program covering only 52,000 persons,
demonstrates the basic uneasiness about President
Kennedy’s vastly greater proposal.”

POLITICS AND MEDICAL ASSISTANCE

Under the philosophy of “Tax and tax; spend
and spend; elect and elect,” government planners
in this country today have turned the entire ques-
tion of medical care for our aged into a political
stratagem. The political implications should be
obvious.

If we permit a medical assistance program to
be tied to Social Security, at every national elec-
tion there will be new demands for increased
benefits. Some politicians who desire office, re-
gardless of convictions, will make more extrava-
gant political promises to our elderly people to
extend and increase every conceivable type of
medical benefit and service, irrespective of need
or ability to pay. It is not inconceivable that, if

Vol. LII, No. 6

Journal of Iowa Medical Society

327

such a program is adopted, the day might come in
the near future when a person’s income tax will
be exceeded by his Social Security deductions.
Though now the aged are described as those per-
sons 65 and over, I foresee the day when as a re-
sult of pressure groups, with the shorter work-
week, with more leisure activity, with higher pay
for less productivity, pressure for reducing the
age for receiving benefits will increase, and the
age limit will drop until every mature person may
be regarded as a “needy aged citizen.” . . . Then
we shall have had it.

Why isn’t there enough accent put upon the
necessity of making sure that there are enough
doctors for all the people who get sick in this in
this country — a point the Administration ignores
entirely.

The number of medical school applicants has
steadily declined — from 24,242 applicants in the
school year of 1948, to 14,951 in the school years
of 1959-1960. The problem which you doctors, and
we in government, should concentrate upon is:
What can be done to assure our people enough
doctors? How can we revive the principle of
private responsibility that has made us the great
nation that we are?

Several colleagues of mine on the Finance
Committee of the United States Senate verify the
opinion that the actual cost of the Social Security
approach will be billions of dollars above and
beyond the official estimates. In the past their
estimates have been far more accurate than the
so-called statistics of government.

May I suggest further that if the present trend
toward eroding the value of the dollar continues
it will deprive those who depend on their savings,
dividends, stocks and pensions and Social Security
retirement funds of their independence, and force
them to become unwilling wards of the govern-
ment— not only for medical care, but for other
necessities as well.

The fact of the matter is that there has been
an increasing erosion of our voluntary free enter-
prise system. In every field, political effort is at-
tempting to establish a government planned econ-
omy over our private enterprise system.

The record shows that the federal government
is attempting more and more to acquire power
from the people, from the states and from the
Congress, and to centralize it in the bureaucratic
agencies.

I could talk to you indefinitely about this drive
toward power through spending, giving detail after
detail; the facts are clear, but time is limited.

In fact, between January 10 and May 1, the
Administration has made 62 requests of Congress
involving more spending and 25 requests for more
power. Despite campaign promises of almost two
years ago, it is obvious that no real effort has
been made to cut spending or balance the nation-
al budget. Power through spending and control

of our economy through taxes — and a vast bu-
reaucracy— this seems to be the pattern, and its
prospects are ominous.

If all the programs are adopted which the so-
called New Frontier advocates, this could become
our last Frontier.

Before I conclude, I want to say that all of us
are inclined to forget the contributions which pri-
vate medicine has made to the American people
and the world. By way of illustration, remember
the great influenza epidemic of 1917-1918 in which
500,000 died in three months and another 500,000
were permanently damaged. You physicians seem
to have conquered this. Thanks to you, we haven’t
had such epidemic losses since then. The other
great strides you have made in solving the cause,
relief and cure of human disease are phenomenal.
This progress has been made under a free system.
Its record cannot be matched if government takes
control. In fact, it can only deteriorate.

Your profession has given every American,
child and adult, the expectation of a longer life
and better health. Now the bureaucrats would
take over.

I have often used a quotation from Macaulay
which sums up a great deal. I should like to con-
clude by quoting it to you:

“Nothing is so galling to a people ... as a pa-
ternal, or in other words a meddling, government,
a government which tells them what to read and
see and eat and drink and wear.”

Rehabilitation of Arthritis Patients

The University of Colorado School of Medicine
and other sponsoring organizations will present a
three-day postgraduate conference on the manage-
ment and rehabilitation of patients with arthritis,
in Denver on July 5, 6 and 7. This conference is
unique in that it is designed especially for the
wide range of health professions active in the care
of such patients. Concepts of disease mechanisms,
diagnosis, management and rehabilitation will be
among the subjects discussed.

The guest faculty will include, among others,
the following physicians: Ephraim P. Engleman,
M.D., president of the American Rheumatism As-
sociation, San Francisco; Ronald Lamont-Havers,
M.D., medical director of the Arthritis and Rheu-
matism Foundation, New York City; Harold S.
Robinson, M.D., medical director, British Columbia
Section, Canadian Arthritis and Rheumatism Soci-
ety, Vancouver; and Donald L. Rose, M.D., chair-
man, Department of Physical Medicine, University
of Kansas School of Medicine.

For further information, address the Office of
Postgraduate Medical Education, University of
Colorado Medical Center, 4200 East Ninth Avenue,
Denver 20.

328

Journal of Iowa Medical Society

June, 1962

Nuclear Medicine to Be Major Topic
At AMA Annual Meeting in Chicago

“Medicine in the Atomic Age” is the theme of
the American Medical Association’s 111th annual
convention which will be held at McCormick Place
in Chicago, June 24-28. In support of that theme,
a special half-day program entitled “Nuclear Med-
icine— Present Achievements and Future Prom-
ise,” will be presented on Tuesday morning, June
26, under sponsorship of the AMA Council on
Scientific Assembly. Program chairman is Dr. Lee
E. Farr, of the Brookhaven National Laboratories,
Upton, New York, a member of the Council, and
the moderator will be Dr. Stuart W. Lippincott,
also of Brookhaven.

With more than 500,000 medical patients a year
in the United States now receiving radioactive
tracers for diagnostic purposes and with another
100,000 getting isotope radiation therapy, radio-
isotopes can no longer be considered curiosities.
The total quantity of radioisotopes sold to indus-
trial and research organizations in the United
States by the Atomic Energy Commission over the
past 15 years has amounted to about 1,300,000
curies of radioactivity. This year alone U. S. users
are expected to buy more than 2,000,000 curies
worth.

The American Medical Association’s nuclear
medicine program will be one of the highlights of
the doctors’ convention. Subjects and speakers are:

— “The Place of Cobalt 60 in the Management
of Human Cancers” by Dr. Gilbert H. Fletcher,
of the University of Texas, M. D. Anderson Hos-
pital and Tumor Institute.

— “The Present Place of Radioactive Iodine in
Management of Thyroid Disease” by Dr. Brown M.
Dobyns of the Cleveland Metropolitan General
Hospital.

— “Why Radioactive Isotopes in Diagnosing Liver
and Kidney Disorders?” by Dr. George V. Taplin,
of the University of California Medical Center,
Los Angeles.

— “Radioactive Fallout — Its Significance for the
Practitioner” by Dr. Charles L. Dunham, of Wash-
ington, D. C.

— “Has the Nuclear Reactor a Future Place in
Cancer Therapy?” by Dr. Farr of Brookhaven.

— “Alpha Particle Radiation in the Pituitary in
Various Chemical States” by Dr. John H. Law-
rence of the University of California at Berkeley.

Side by side with surgeons, radiation specialists
have made great strides in increasing the power
and effectiveness of atomic radiation. Especially in
the last 20 years, developments in nuclear physics
and high voltage engineering have resulted in more
efficient modalities of delivering radiation for the
management of human cancer.

At the Brookhaven National Laboratories, the
first atomic reactor designed exclusively for med-

ical treatment was built. The reactor, actually a
small atomic power plant, produced powerful
gamma rays and neutrons for the treatment of
deep-seated cancer. Neutrons, acting as “atomic
guided missiles,” go straight to the hidden cancer
tissues without harming healthy tissues. The re-
actor also produces radioactive isotopes for treat-
ing cancer.

One of these isotopes is known as Cobalt 60.
Radioactive Cobalt 60 machines, the most power-
ful of those artificially producing nuclear radiation
for cancer treatment, have been installed in many
institutions across the country. The source of radi-
ation is a cylinder of cobalt, one-third of an inch
in diameter and one and one-tenth inches long.
Its small size permits the technician to pinpoint
a radiation beam to the tumor more accurately
than is possible with other technics.

Dr. Fletcher, one of the lecturers on the AMA
program, said that Cobalt 60 therapy “has been a
great step forward in the management of previ-
ously unfavorable types of cancers such as those
of the oropharynx, the advanced cancers of the
uterine cervix, and those of the urinary bladder.
For relief of pain or for prolongation of life by
remissions, as in the lymphomas, it is easier to
deliver the proper dose with much less discomfort
to the patient.

“One of the most promising lines of clinical in-
vestigation is the combination of pre-operative ir-
radiation in surgery of many cancers which yield
poor results to one of the disciplines alone. An ex-
ample of pre-operative radiation studies is found
in lung cancer, cancer of the urinary bladder and
cancer of the breast.”

Only recently researchers at the University of
Maryland reported that they have been using
Cobalt radiation, pre-operatively, on lung cancer
patients for the past six years. The purpose of the
radiation is to kill cancer cells in surrounding tis-
sue that the surgeon may miss. Of 45 patients
treated, 12 are alive from one to three years. In
the studies so far, the cure rate has been increased
to about 10 per cent. Only about five in 100 lung
cancer victims live five years or more.

In his lecture at the AMA meeting, Dr. Farr will
report on a new radiation technic in attacking
brain tumors. Boron salt is injected into patients;
their brain tumors are then exposed to neutrons
from a nuclear reactor. Although the mechanism
is not clear so far, it appears that boron and neu-
tron radiation together produce an effect that
neither produces alone. Studies at Brookhaven
National Laboratories already encompass 10,000
mice and 51 cancer patients. An unusual fact
about the boron-neutron treatment is that it can
be used after maximum doses of other radiation
have been tried and have failed. Also, no damage
is done to surrounding healthy tissue.

Surgical Emergencies

In the Neonatal Period

ROBERT T. SOPER, M.D.

Iowa City

The purpose of this paper is to discuss some of the
conditions which arise during the neonatal period
to threaten the infant’s well-being or life. These
conditions vary as to cause, location, symptoms
produced, and methods of diagnosis and treatment.
However, they have three factors in common. First,
they are present at birth or develop shortly there-
after, within a matter of minutes or hours. Second,
they involve systems which are vital to the infant’s
life. Third, promptness is mandatory in establishing
the precise diagnosis and in instituting appropriate
therapy. These conditions will be discussed as to
cause, symptoms produced and emergency care.
Definitive treatment will be briefly mentioned only
when it differs from emergency care, and then only
in general terms.

Table 1 contains a convenient subgrouping of
these conditions. The first group consists of those
which compromise the upper airway by obstruc-
tion, compression or deviation. These conditions
are somewhat rare and involve only about five per
cent of the babies whom we are considering. None-
theless, they are important to know about, since
any decrease in the airway needs to be recognized
and rectified quickly. Second is the group of con-
ditions which are primary within the cardiopulmo-
nary system and which produce symptoms by
atelectasis, reduction of the venous return to the
heart, shift of the mediastinal structures and in-
terference with respiratory excursions. These are

Dr. Soper is an assistant professor of surgery at the S.U.I.
College of Medicine, and he made this presentation at the
Refresher Course for General Practitioners, in Iowa City,
during February, 1962.

somewhat more common, and involve about one-
third of the babies whom we are discussing. Last
is the group of conditions primary within the gas-
trointestinal tract. These are much more common
but warrant less consideration since the symptoms
which they produce to threaten life are relatively
slower in developing, better understood by most of
us and more easily treated.

Etiology of Neonatal Surgical Emergencies.
Table 2 summarizes the causes of the conditions we
are considering. They are primarily teratological —
that is, they involve failure of normal development
and are either environmental or genetic in origin.

TABLE I

NEONATAL SURGICAL EMERGENCIES

Location:

Upper Airway — choanal atresia, micrognathia,
cystic hygroma, congenital goiter
Cardiopulmonary — Tracheo-esophageal fistula,
diaphragmatic hernia, aortic arch anomalies,
pneumothorax, lobar emphysema, lung cyst
Gastrointestinal — intestinal obstuction,
pneumoperitoneum

TABLE 2

NEONATAL SURGICAL EMERGENCIES
Causes:

Teratological — most important
Transplacental — congenital goiter
Humoral — pneumoperitoneum
Iatrogenic — pneumothorax, lobar emphysema,
pneumoperitoneum

329

330

Journal of Iowa Medical Society

June, 1962

Congenital goiter of the newborn, however, oc-
cupies a special place in that it is produced by a
thyroid hyperplastic stimulus of maternal origin,
transmitted to the infant across the placental
barrier. Next are humoral factors which produce
the acute, so-called stress ulcer occasionally seen
in the newborn infant, which commonly perforates
to produce pneumoperitoneum. Finally, there is a
group of iatrogenic origin, resulting from overly
zealous efforts at artificial respiration, or the force-
ful passage of nasogastric or rectal tubes and rectal
thermometers.

UPPER AIRWAY EMERGENCIES

Posterioir Choanal Atresia: Posterior choanal
atresia is a developmental defect in which the
buccopharyngeal membrane fails to perforate
(Figure 1). The buccopharyngeal membrane runs
from the sphenoid bone down to the hard palate,
and if retained, it produces complete closure of
the posterior nasal air passage. This defect occurs
in female babies slightly more often than in males,
and is bilateral as often as unilateral. There is
also an associated hypoplasia of the sinuses and
palate.

Symptoms with unilateral choanal atresia occur
only with obstruction of the patent side by mucous
plugs or exudate from an upper respiratory in-
fection and, therefore, are varied and somewhat
less predictable than those resulting from bilatral
involvement. In the latter disorder, symptoms of

upper-airway obstruction are produced very early.
Babies normally breathe through the nasal pas-
sages as a matter of choice, and of necessity during
oral feedings. Consequently, infants with bilateral
choanal atresia are mouth breathers, and develop
severe respiratory distress when oral feedings are
attempted. Diagnosis is simple indeed. It involves
passing a catheter through the nose and meeting
an obstruction in the posterior nasal passageway.

If the obstructing membrane is composed of
merely two layers of mucous membrane, then
treatment is correspondingly simple. It involves
perforating this membrane with a blunt instrument
and dilating the passageway, perhaps at weekly
intervals, to keep the airway patent. On the other
hand, this membrane is occasionally fortified by
cartilage or bone, and if such is the case, then a
definitive plastic excisional procedure is required.
This definitive operation is not carried out in the
newborn period, however, and with bilateral
atresia, auxiliary methods of feeding must be in-
stituted, such as a gastrostomy tube, until the cor-
rective operation can be performed.

Micrognathia: Micrognathia, or small jaw, is per- ■
haps better recognized as the “Andy Gump syn-
drome” (Figure 2). It involves a hypoplasia of the
mandible, jaw and tongue, and a failure of support
of these hypoplastic structures. Whenever the in-
fant is placed in the supine position, the lower jaw
and associated structures gravitationally prolapse
posteriorly to obstruct the pharynx in this area.

Choanal Atresia

BUCCOPHARYNGEAL

MEMBRANE

sxsipp i ■

Figure I. Posterior choanal atresia, a congenital anomaly in which the buccopharyngeal membrane has failed to separate.

Vol. LII, No. 6

Journal of Iowa Medical Society

331

Figure 2. Note the obstruction of the oropharyngeal air-
way (in black) when the infant with micrognathia is supine.
The mandible and tongue prolapse posteriorly.

The diagnosis can be made at a glance. These
babies have a very characteristic profile which is
not confused readily with any of those produced
by other entities. Therapy, likewise, is often simple,
and involves positioning the infant on his side or
abdomen so that the jaw will not prolapse and ob-
struct the airway. Infants with severe degrees of
involvement — and the degrees do vary somewhat
— occasionally require temporary tracheostomy or
auxiliary feeding methods. Ultimately the infants
will outgrow this hypoplasia and lack of support.
By the time they are three to six months of age,
obstruction of the esophagus and trachea improves,
and then the problem becomes one of cosmetic
correction which will not be considered in this
paper.

Cystic Hygroma: Congenital cystic hygroma is
recognized (Figure 3) as a unilateral, cystic and
generally rather soft mass arising on one side of
the neck. It is composed of abnormal collections of
lymph or tissue fluid within endothelial-lined spaces
which have not developed proper connections
with the thoracic duct. The condition is ordinarily
progressive. The cysts are multiloculated so that
they do not lend themselves well to needle aspira-
tion. These lesions can be of considerable size at
the time of delivery, and will progressively en-
large, encroaching upon and deviating the trachea.

The diagnosis is again simple, for it can be made
by observation and transillumination. Treatment
depends upon the degree of tracheal obstruction.
Sometimes, as an emergency measure, simply
changing the position of the infant’s head and neck
will suffice to give an adequate airway. Sometimes
passage of a nasotracheal tube is mandatory, and
occasionally emergency tracheostomy is necessary.
Aspiration of the mass to reduce its size is gen-

Figure 3. Infant with large cystic hygroma arising in the
left cervical area and seriously interfering with the airway.
The baby is being anesthetized via an orotracheal tube pre-
paratory to surgical resection.

erally ineffective because of its multiloculated na-
ture. Furthermore, aspiration introduces the pos-
sibility of infection.

Definitive management consists of complete ex-
cision. The cysts tend to intertwine around im-
portant neurovascular structures of the neck, and
so the definitive surgical procedure is technically
difficult in many instances.

Congenital Goiter: Congenital goiter is due to a
thyroid hyperplastic stimulus originating in the
mother which is transmitted across the placenta
to stimulate the embryo’s thyroid. Until well into
this century, the commonest cause for this stimulus
was iodine deficiency in the maternal diet. Today,
maternal thyroid-stimulating hormone or maternal
ingestion of anti-thyroid drugs are most often in-
criminated. Very rarely is the stimulus due to ma-
ternal diets that are high in thiouracil compounds
such as are contained in rutabagas and soybeans.

Again, diagnosis is simple (Figure 4). It can be
made by observation and palpation of a solid mass
low in the neck which is almost symmetrical bi-
laterally, and which is connected by a bridge or
isthmus across the midline. The symptoms are pro-
duced by the same mechanism by which goiters
cause airway problems in the adult, but because
the infant’s trachea is more collapsible, the con-
dition is more likely to be emergent at this age.
Emergency treatment must be tailored to the de-
gree of tracheal obstruction. Occasionally, simple
positioning of the neck will provide an adequate
airway or a nasotracheal tube may need to be
passed, as illustrated in Figure 4. On the other
hand, if the thyroid is large and if the infant is in

332

Journal of Iowa Medical Society

June, 1962

real distress, then consideration must be given to
emergency tracheostomy and isthmusectomy.

Any of the measures employed to provide an air-
way in patients with congenital goiter are tem-
porary, since the stimulus to thyroid hyperplasia
is withdrawn at the moment of delivery. The gland
will quickly begin to regress in size, and may be
barely discernible by the time the infant is one to
two weeks of age.

CARDIOPULMONARY ANOMALIES

Esophageal Atresia: Microscopic sections of a
human embryo about 4 to 4% weeks of age will
show a single tube lined by epithelium located in
the mid-mediastinal area. This tube quickly divides
in a longitudinal plane into two separate tubes, the
definitive trachea anteriorly and esophagus pos-
teriorly. Interference with this splitting mechanism
results in esophageal atresia with tracheo-esopha-
geal fistula.

Figure 5 illustrates the common anatomic ar-
rangement seen in this condition. Variations on
this theme are seen in approximately 90 per cent
of these children, namely a blind proximal esopha-
geal pouch, the distal esophagus communicating
with the trachea by means of a fistula at or near
the carina. The symptoms can be predicted from
the anatomic abnormality. The nurse in the new-
born nursery usually makes the initial observation

Figure 4. Infant with congenital goiter producing tracheal
airway obstruction. Note the facial edema due to interfer-
ence with cervical venous drainage. The nasotracheal tube
was necessary to provide an emergency airway.

that the infant appears “mucus-y.” The baby seems
to be producing an excessive amount of saliva.
This illusion is due simply to overflow and regurgi-
tation of normal amounts of saliva from the blind
esophageal pouch. Next, the observant person will
notice that there is some degree of abdominal dis-
tention. This is due to inspired air passing into the
stomach via the fistula during each respiratory
cycle. When oral feedings are attempted, the infant
develops acute distress, with coughing, explosive
regurgitation, vomiting, cyanosis, etc. Finally, be-
cause of the fistula there is retrograde passage of
gastric juice from the stomach upward into the
lung fields, resulting in chemical pneumonitis.

The diagnosis is once more reasonably simple.
It involves the passage of a soft, No. 8 French
rubber catheter gently through the nose, and
recognizing that it impinges in the lower cervical
or upper mediastinal area. This can be confirmed
by using a catheter with a radiopaque tip, and
then finding by means of a chest radiograph that
the tip has coiled up in the high mediastinal area.
Further confirmation of the diagnosis of esophageal
atresia can be established by injecting 2-3 cc. of a
water-soluble radiopaque material through this
same tube to outline the proximal esophageal
pouch. Larger volumes of radiopaque material are
not needed for diagnosis and, indeed, might be
dangerous because of overflow aspiration. The
esophageal pouch should be aspirated until empty
at the conclusion of the radiographic study.

Emergency treatment of esophageal atresia in-

Figure 5. Esophageal atresia with tracheo-esophageal
fistula, common type.

Vol. LII, No. 6

Journal of Iowa Medical Society

333

eludes periodic aspiration of mucus and saliva from
the atretic proximal esophagus. Oral feedings must
be withheld. The infant should be kept in a head-
up position (reverse Trendelenberg) to obviate
retrograde passage of gastric juice into the lungs.
Definitive operative management is technically
difficult and is not germane to the scope of this
paper.

Pneumothorax: Pneumothorax of the newborn
is generally due to overzealous attempts at resusci-
tation which result in alveolar rupture and dis-
section of air across the visceral pleura and into the
thoracic cavity. Diagnosis is to be suspected in a
baby who does not respond well to resuscitative
efforts and who develops a hypertympanitic hemi-
thorax with diminution in breath sounds and a
shift of the cardiac impulse to the contralateral
side. Confirmation is afforded by a single upright
radiograph of the chest, as demonstrated by Fig-
ure 6, which reveals air in the thoracic cavity,
atelectasis of the ipsilateral lung, shift of medias-

tinal structures to the contralateral side and some
compression of the other lung.

Treatment is by simple needle aspiration or un-
derwater-seal tube drainage, allowing reexpan-
sion of the collapsed lung and sealing of the leak
(Figure 6). Prevention, in the guise of gentle and
careful attempts at resuscitation of the newborn
infant, is still better treatment.

Progressive Pulmonary Emphysema: A condition
allied to pneumothorax is progressive pulmonary
emphysema in the newborn. Again, this is a con-
dition due to overzealous resuscitative efforts, with
rupture of alveolar septa allowing inspired air to
pass interstitially within and through pulmonary
tissue. Occasionally this is confined to one lobe,
but it often involves multiple lobes of each lung.

Figure 7 is a photomicrograph which illustrates
this alveolar-septal rupture. Treatment is unsatis-
factory because of the diffuseness of the lesion, and
excisional therapy is reserved for those localized
to one lung or to a portion thereof.

Figure 6. Roentgenogram at left illustrates neonatal pneumothorax on the left side; note the collapsed ipsilateral lung and
the shift of the mediastinal structures to the right. The photograph on the right is of the same patient 24 hours after place-
ment of an intercostal tube connected to underwater-seal drainage; the changes have been completely corrected.

334

Journal of Iowa Medical Society

June, 1962

Figure 7. Photomicrograph of lung in baby with progressive
pulmonary emphysema. Note the extensive rupture of alveolar
septa.

Congenital Cystic Disease of the Lung: Con-
genital cystic disease of the lung is a rarely-en-
countered condition in which there is ball-valve
effect in the bronchus leading to a segment of lung.
Inspired air enters the involved area of lung and
is entrapped therein because of the retrograde
bronchial obstruction, resulting in progressive
overdistention. This collapses the remaining por-
tion of the ipsilateral lung and shifts the medias-
tinal structures to the opposite side. Figure 8 illu-
strates the progression of this phenomenon during
a 24-hour period of time. Figure 9 demonstrates the
lesion grossly. Note the extremely overinflated
upper lobe and the collapsed lower lobe on the
same side.

Emergency treatment consists of tube under-
water-seal drainage of the cystic area of lung.
Artificial respiration is mentioned only in condem-
nation, since this worsens the overdistension. The
baby should not be intubated or artificially re-
spired until the surgical team is ready to perform
definitive thoracotomy and resection of the over-
distended lobe.

Congenital Diaphragmatic Hernia: The last car-

Figure 8. Roentgenogram at the left is of an infant with a congenital cyst of the right lung; note the rarefaction in the right
hemithorax, with shift of the mediastinal structures and compression of the contralateral lung. Roentgenogram on the right
is of the same infant 24 hours later, showing progressive worsening of the changes.

Vol. LII, No. 6

Journal of Iowa Medical Society

335

diopulmonary condition to be discussed is con-
genital diaphragmatic hernia. Eighty per cent of
these occur through the foramina of Bochdalek, or
the pleuroperitoneal canals. These foramina are
located in the upper posterior portion of each
hemidiaphragm. They represent the last part of
the diaphragm to acquire fibromuscular support
during embryologic development, and effect the
separation of the pleural cavity above from the
peritoneal cavity below. It is understandable that
this is the site most commonly involved in an em-
bryologic failure of closure and a consequent con-
genital hernia. About 90 per cent of the hernias
involve the left side because of the tamponading
effect of the liver which is located on the right
side. However, Figure 10 is a photograph taken at
postmortem of a baby with a hernia of the right
side of the diaphragm. Notice the relatively large
amount of the infant’s viscera which has herniated
into the right hemithorax. The heart is displaced to
the left, and there is severe atelectasis of both
lungs. Obviously, this is a situation incompatible
with life. The respiratory problem will be progres-
sive as the child swallows air and distends the
herniated intestine, producing a true emergency
that must be recognized and treated most quickly.

Diagnosis should be suspected in an infant in
respiratory distress with a hypertympanitic hemi-
thorax, a diminution in the breath sounds on that

Figure 9. Operative photograph illustrating cystic disease
in the upper lobe (to the right) and compression atresia of
the lower lobe (to the left).

side and a shift of the cardiac impulse to the op-
posite side. Upright radiographs of the chest reveal
air-filled viscera within the chest and the shift of
the cardiac shadow.

Emergency treatment consists of administering
artificial respiration, preferably by means of naso-
tracheal or orotracheal tube, although bag and
mask is a perfectly acceptable alternative. Naso-
gastric suction should also be instituted.

Figure 10. Photograph taken at postmortem of an infant with congenital hernia through the right foramen of Bochdalek.
Note the hollow viscera filling the right hemithorax and resulting in displacement of the heart to the left side and compres-
sion atelectasis of both lungs. The liver fills most of the peritonea! cavity which can be seen.

336

Journal of Iowa Medical Society

June, 1962

Definitive therapy is difficult and, in essence,
consists of reduction of the herniated viscera and
repair of the diaphragmatic defect. Most of these
defects can be closed by sutures, but occasionally
they are so large that a prosthesis is required to
bridge the gap. One third of these babies will have
other associated major congenital anomalies.

GASTROINTESTINAL ANOMALIES

Pneumoperitoneum: Pneumoperitoneum arising
in the neonatal period is, fortunately, a quite rare
catastrophe. Most are due to perforation of hollow
viscera proximal to mechanical or functional ob-
structions. The mechanism is the same as that by
which perforation occurs with ileus in any other
age group, namely an increase in intraluminal
pressure, compromised blood supply, ischemic
necrosis and perforation. There is, in addition, a
group of perforations of the stomach and duode-
num which are either acute, punched-out stress
ulcers of possible humoral origin, or are linear
lacerations due to forceful passage of nasogastric
tubes or secondary to unknown mechanisms. The
mortality rate from pneumoperitoneum in the
neonatal period was about 90 per cent as recently
as 20 years ago, and even today approximates 50
per cent.

Diagnosis should be suspected in any acutely ill,
shocked infant with a progressively distending,
hypertympanitic abdomen and diminished bowel
sounds. It can be confirmed by a single upright
radiograph of the abdomen (Figure 11) which
demonstrates free air within the peritoneal cavity.

Emergency care includes nasogastric suction, the
administration of parenteral fluids and electrolytes,
antibiotics and other supportive measures. Defin-
itive management in the form of surgical explora-
tion should be carried out as expeditiously as pos-
sible to close or exteriorize the perforation.

Intestinal Obstruction: Intestional obstruction in
the newborn will be discussed only very briefly.
Table 3 summarizes the more common causes of
ileus in this age group. The symptoms are second-
ary to intestinal dilatation proximal to the point
of obstruction, and include elevation of the dia-
phragm with interference of respiratory excursions
and compression of the inferior vena cava resulting
in a reduction of the venous return to the heart.

TABLE 3

CAUSES OF ILEUS
IN THE NEWBORN

Stenosis

Atresia

Annular pancreas
Malrotation of midgut
Volvulus
Meconium ileus
Hirschsprung’s disease
Imperforate anus

The threat of aspiration of vomitus with sudden
death is possible in any infant with untreated in-
testinal obstruction.

The diagnosis is generally reasonably simple to
make: the baby does not pass meconium normally,
has progressive abdominal distention and vomits
bile. Supine and upright radiographs of the abdo-
men confirm the presence of obstruction and often
reveal the level of the gastrointestinal tract in-
volved; they will not indicate the nature of the
obstruction. However, further radiographic studies
are rarely indicated, since they seldom help in
elucidating the nature of the obstruction, and
since exploratory laparotomy is mandatory any-
way for definitive therapy. Radiation exposure of
the infant is another factor for consideration in
this respect.

Emergency management employs the same prin-
ciples as those for infants with pneumoperitoneum
and will not be reiterated. As alluded to pre-
viously, definitive management requires explora-
tory laparotomy and correction of whatever ob-
structing mechanism is found.

CONCLUSION

Some of the more important conditions which
arise during the neonatal period to threaten life
have been discussed. The simplicity of diagnosis
and emergency care has been emphasized, as well
as the need for precision and promptness in carry-
ing out these measures. Specialized technics and
personnel are necessary for definitive care in only
a few of the conditions that have been discussed.

Figure II. Upright roentgenogram of an infant showing a
large amount of free air above the liver and beneath the
diaphragm.

The Management of the

Patient With Headaches

ADRIAN OSTFELD, M.D.

Chicago, Illinois

When I get ruminative about headache syndromes,
I sometimes conclude that there are only two
kinds of headaches: those which are relatively
mild and which seldom come to the attention of
the physician but get better by themselves, and a
second kind that are quite severe, which almost
invariably come to the attention of physicians,
and which nothing seems to help, despite the ef-
forts of the patient and the physician. However, I
feel that way only during pessimistic moments,
perhaps after being unable to help two or three
patients in a row. There is a middle ground, and
it is that middle ground that I want to discuss.

What I should like to do, very simply, is to begin
with the commonest type of headache syndrome,
then to progress to the next-most-common type,
and so on until I have covered the headaches
that make up approximately 90 to 95 per cent of
those that are clinically encountered.

When faced with a new headache patient, the
physician has certain comforts. First, in excess of
95 per cent of all headache syndromes are caused
primarily by disorders involving structures out-
side the skull, rather than inside, and less than
one per cent of all headaches are caused by ma-
jor, life-threatening illness. Thus, the chances of
missing a very serious disorder by misdiagnosing
headache are not great. Rather, the problem is
one of trying to relieve pain, reduce misery and
increase productivity for the patient. Consequent-
ly, the emphasis is somewhat different in treating
this syndrome, as compared with treating many
other medical disorders.

SKELETAL-MUSCLE-CONTRACTION HEADACHES

The first kind of headache syndrome, which, as
I indicated, is the commonest, is the so-called
skeletal-muscle-contraction headache that is var-
iously called “tension headache” or sometimes
“psychogenic headache.” It is the sort that appears
most often on television, usually in the person of

Dr. Ostfeld, an associate professor of preventive medicine
at the University of Illinois College of Medicine, made this
presentation at the Refresher Course for General Practition-
ers, at Iowa City, in February, 1962.

an actress portraying a distraught housewife. The
pathophysiology of this headache is believed to
be an increased contraction of muscles of the face,
neck, and scalp, together with a vasoconstriction
of the nutrient arteries of these vessels. Thus the
mechanism of the pain in part represents an in-
creased skeletal-muscle contraction, and in part an
ischemia at the very time when more blood is
needed.

This pain is described by patients as being felt
usually in the occiput or the neck, the shoulders,
sometimes the top of the head and, less commonly,
all across the forehead. It is almost always bi-
lateral. The pain is characteristically dull, deep,
aching and non-throbbing. This is the kind of
headache which may either be brought on or be
aggravated by intense visual activity — a long drive,
ill-fitting spectacles and prolonged watching of
television, prolonged reading, etc. However, these
usually serve only to trigger individual headaches,
rather than to provide a background on which
most of them occur. The great majority of patients
who have frequent headache attacks of this kind
will also have associated personality and mood
disorders, and these may take the form either of
anxiety and preoccupation about what may hap-
pen next or depression, blues, pessimism, and “I’m
no good,” “Nothing’s worth very much” obses-
sions. Once such a patient begins to talk in this
way, it is rather hard to get him to deal with any-
thing else. This is the background, or what in
preventive medicine we call the “remote host fac-
tor,” whereas the proximal factors are individual
episodes of prolonged reading, ill-fitting spectacles,
and so forth. This is not to say that these head-
aches are imaginary or even that the patients
complain excessively. If you want to demonstrate
that such a thing is present, you have only to put
an electromyograph on the pertinent skeletal mus-
cle, and you’ll find long strings of potentials in-
dicating excess skeletal-muscle activity. Now these
headaches may last for minutes, for hours, for
weeks or for months. These are the kind that
almost everyone gets.

I want to be very candid about the general ef-
fectiveness of treatment in these disorders. Phar-
macotherapy, at the present time, is not highly
effective. First of all, most of the so-called tran-
quilizers do not appreciably help this kind of
disorder. Chlorpromazine — Thorazine — and related

337

338

Journal of Iowa Medical Society

June, 1962

phenothiazines are not particularly effective in
conditions of this sort. Nor are the rauwolfia alka-
loids. Perhaps the most effective of the so-called
tranquilizers in this disorder is meprobamate —
Equanil or Miltown — and this drug is effective
probably not because of its tranquilizing prop-
erties but because it depresses certain kinds of
neural activity in the spinal cord and, possibly, in
those parts of the brain stem that are concerned
with cranial nerve activity. Specifically, it depress-
es interneurones in the spinal cord and tends to
relax skeletal musculature.

Other somewhat simpler measures for the man-
agement of this particular kind of headache con-
sist of old standbys — warm baths, salicylates and
small doses of barbiturates. I’m not prepared to
take a stand on which salicylate gets into the
blood stream faster, causes less gastrointestinal
upset or acts “faster . . . faster . . . faster.”

As for what can be done to readjust the life
situations of these patients, I think that the phy-
sician has an obligation to spend a bit of time see-
ing what specific things are wrong, if anything,
and asking the patient to direct his attention
toward improving them. I have not observed that
psychiatrically oriented treatment is effective in
most cases. Why this is true, I don’t know. I sup-
pose that it is because of the basic inflexibility of
most of these patients. I am not very sanguine
about the amount of help that they can get in this
particular kind of disorder. I don’t mean that these
emotional factors aren’t relevant; rather I regard
them as most relevant of all, but the degree of
relief that the majority of patients have achieved
through attempts to deal with the emotional factors
is quite minimal.

MIGRAINE

Now the next most common headache syndrome
is the one about which most is written, and I
deliberately did not put it first because in spite of
the volume of literature about it, it is not the com-
monest kind of headache by a long shot. It is the
so-called migraine variety. There is confusion
about migraine, for the literature itself is con-
fused. Some people make the diagnosis only if
pre-headache visual phenomena are present, such
as scotomata, certain auras and various kinds of
transient neuromuscular weakness. This all ap-
pears to be rather irrelevant. I certainly don’t in-
tend to spend any time on our own investigation
in this area, but if you assume that the sine qua
non of the migraine syndrome is dilatation, usual-
ly of extracranial but sometimes also of intra-
cranial arteries, then you have won the patho-
physiologic battle.

There is no profit in trying to base your diagno-
sis on the presence or absence of scotomata, pre-
headache visual phenomena, or gastrointestinal
disturbances involving the liver. The most profit-
able definition of migraine, in terms of what pa-

tients tell us can be couched in four terms: (1)
There is a positive family history of the head-
aches. This you will get in 75 to 90 per cent of
cases, if you inquire carefully. (2) The headache
is unilateral at its onset, although not necessarily
as it progresses. (3) There is some kind of upper-
gastrointestinal disturbance in association with
the headache. This is seldom vomiting. Usually it
takes the form of anorexia and nausea. Vomiting
is unusual, except after drugs have been given in
an attempt to relieve the headache. (4) The next
criterion is one that has been established again
with ease at a large university hospital, but is
established only with difficulty under the condi-
tions that obtain in private practice. It is a good
therapeutic response to about .4 to .5 mg. of ergot-
amine tartrate injected subcutaneously or intra-
muscularly within one hour after the onset of
headache. If a patient is seen under these cir- I
cumstances, a therapeutic trial of this material is !
warranted.

Now these are the most important criteria for
diagnosing vascular headache of the migraine
type. As I said, the pathophysiology is a dilatation
of extracranial vessels, usually, and intracranial
vessels less commonly. What one observes in
about a third of the cases is that the superficial
temporal or the posterior auricular or occipital
arteries will be found enlarged and tender to
palpation. This is a common clinical finding during
a vascular headache of the migraine type. One
that I don’t think is emphasized enough is that
the relevant artery and the scalp around it are
quite tender to palpation, and that this tender-
ness persists for as long as two or three days after
a severe headache. The tenderness is appreciated
by the patient in that his hat makes his head sore,
his glasses irritate his scalp where the bows touch
it, and that a comb, when he runs it through his
hair, reaches certain sore or irritated spots.

The scotomata occur if there is vasoconstriction
in a retinal artery or its branches, or in those in-
tracranial vessels which supply areas XVII and
XVIII of the occipital cortex. This does not occur
in every vascular headache of the migraine type,
and if it doesn’t, the headache goes on and is very
much the same.

There are certain other kinds of phenomena
which are associated with migraine. These are ac-
cumulations of fluid occurring hours to days be-
fore the onset of the headache attack, and you may
want to prevent these accumulations of fluid from
occurring through the use of various kinds of
diuretics — not that you can always do this. You
can “iron out” the fluctuations in weight of these
patients without affecting the frequency and sever-
ity of the headache attacks. Thus the inference is
plain that the headaches and periodic fluctuations
in weight gain are concomitant but independent
manifestations of some disorder in the patient.

Now as for what we might call again “host fac-

Vol. LII, No. 6

Journal of Iowa Medical Society

339

tors,” — what in the patient causes these things, and
“environmental factors” — what in the environment
causes them — there are really only two things that
we know very much about at the present time.
Though there is one of them that a physician can
do nothing about, he can do something to control
the other, provided that he has a bit of luck and
a cooperative patient. This disorder appears to be
genetically determined. In the language of the
geneticists, it seems to be inherited as a simple
Mendelian recessive with about a 70 per cent
penetrance. Now, eliminating the jargon, I can
interpret that as meaning that if both parents have
this kind of headache, the chances that any one
of their children will have it are about seven out
of 10. When only one of the parents has it, the
chances of any one of the offspring’s having it
are about 4.5 out of 10, and when neither parent
has migraine headaches clinically but is a carrier,
so to speak, the chances of a youngster’s having
them run about one out of four. In arriving at
these statistics, studies were made of family
groups in which at least one member had migraine
headaches.

Nothing can be done about a person’s genetic
equipment, and what a migraine patient has in-
herited is probably some instability and irregular-
ity of the circulation that comes from his carotids.
There is something peculiar about the circulation
in the head of a human being. He blushes in his
head, neck and shoulders, but a similar degree of
vasodilatation has not been observed in other parts
of his body. Extracranial arteries can dilate from
the size of the lead in a pencil up to the size of
the pencil itself. No similar vasodilatation occurs
in the arteries of the extremities and viscera. This
phenomenon seems to have a great deal to do with
the disorder that I have been discussing.

So much for the inflexible host factor. The
other thing that seems to trigger headaches con-
sists of certain patterns of living. The patterns
of behavior of which I speak have nothing to do
with neuroticism, or with anxiety or depression,
in the ordinary sense. They have to do with the
ways some people have of attacking their tasks.

Now if I were to draw the picture of the typical
migraine-prone individual, I should portray him
as one with the genetic predisposition, of course,
but he would also be one who characteristically
juggles three or four balls in the air at the same
time, and one who always manages to make the
simplest task as complex and difficult as possible.
He fails to distinguish between important and un-
important things, and characteristically is in a
much higher state of physiological readiness than
his tasks really demand.

A simple example might be pertinent. A mi-
graine-disposed housewife — one who is predisposed,
genetically, to the development of migraine head-
aches— gets a phone call from her husband at 10
o’clock in the morning, saying that he is bring-

ing four guests home for dinner. She is an orderly
sort of person who has planned, on that particular
day, to clean the downstairs and to do the laun-
dry. She is not going to change her schedule just
because her husband insists on bringing guests
home. However, she has certain standards about
what constitutes an adequate home and about
what she should do for her husband, and she will
not send to the restaurant for ham or fried
chicken. She insists on preparing an adequate
meal herself.

So far, this is all very well and good. However,
she decides that each of her tasks must be done
extremely well and with singular care, and when
she has made that decision, her body goes into a
state of unusual readiness — hyper-alertness, hy-
per-arousal. She subdivides her day so that she
vacuums for 15 minutes, then dashes off to look
at the food, then runs to the basement to check
on the washing machine, and thus is on a merry-
go-around throughout the entire afternoon.

The house will be clean and all her other tasks
will be done. The dinner will be excellent, and
the dishes will not have been left in the sink. At
about two o’clock in the morning, after every-
thing has been put away, she will say, “Thank
goodness, that’s over.” But at that point her head-
ache will begin.

It is quite typical for this disorder to start “after
the battle,” and there must be some kind of as-
sociation between that portion of the brain stem
and thalamus which is concerned with arousal
mechanisms, the so-called reticular activating sys-
tem, and the portions of the brain which are con-
cerned with vasodilatation. There must be some
sort of let-down phenomenon that induces this
particular kind of disorder.

One might suppose that simply by pointing out
to such a lady that her behavior has a share in
causing her trouble, a great deal might be done
about reducing the frequency of her headaches.
But the task isn’t all that simple.

A state of super-readiness and over-conscien-
tiousness contributes to prominence and success in
business, in professional activities, and even in
women’s clubs. If one has high standards, if he
drives himself and if he does extremely well in
everything he attempts, his efforts “pay off.” In
consequence, many people are willing to suffer an
occasional headache. The reward, if not simply
the self-satisfaction that comes from doing a good
job, is ample recompense for the pain. Only if
the patient reaches the point where he thinks he
has “had enough,” will he be ready to consider
alternative behavior patterns.

In my experience, the patients who have come
to recognize that this pattern of behavior is theirs
and who have been willing to adopt alternative
ways of doing things have amounted to no more
than 25 or 35 per cent. Thus, many people know
what is wrong but will do nothing to change it.

340

Journal of Iowa Medical Society

June, 1962

and it seems to me that the physician’s respon-
sibility ends with pointing out, in a common-sense
way, how the patient can avoid trouble by arrang-
ing his life differently.

TREATMENT FOR MIGRAINE

What about drugs for this kind of disorder?
There are drugs that can be administered for the
the acute headache attack, and fortunately — though
only recently— a useful prophylactic agent has
been introduced. Of the medications that can be
used in treating particular attacks, ergotamine
tartrate remains the drug of choice.

If ergotamine tartrate can be administered
parenterally, so much the better. If not the pa-
renteral, the next most effective form is the sup-
pository. Only about 30 per cent of orally-admin-
istered ergotamine tartrate is absorbed through
the gastrointestinal tract, and thus the pills are
not nearly so effective as are the suppositories
or the injections. If one must give the pills, it is
probably better to give those preparations in
which caffeine is combined with ergotamine tar-
trate, and which also contain an anti-emetic.

The labels of most bottles of ergotamine tar-
trate for oral administration contain the state-
ment that two pills should be taken at the start
of a headache, and then one pill should be taken
every half-hour until the headache is gone. I
think those instructions inappropriate. We know
that if ergotamine tartrate is taken an hour or
more after the start of a headache, the headache
will not be relieved in the majority of cases. The
important thing to do is to get an effective dose
into the body early during the headache. Thus, in-
stead of administering two pills initially and then
one every half-hour, it seems to me that the
patient should be told to find out what dose, taken
all at once, will relieve a majority of his head-
aches— whether it be two, three or four pills — and
then to take that dose as soon as possible, and
none thereafter.

I am well aware of the literature regarding the
toxicity of ergotamine tartrate, but in administer-
ing the drug to several hundred patients, I have
seen only one case of such toxicity marked by
anything other than nausea and vomiting. Thus,
I think that the toxicity, though it does occur, has
been overrated. A great deal of the literature
dates back to the early days when people were
taking large amounts of it because not much was
known about it, and occasional cases of gangrene
occurred.

Certainly there are some contraindications to
ergotamine tartrate: moderately severe essential
hypertension, known cerebrovascular disease, cor-
onary artery disease, peripheral artery disease,
disorders of the liver, pregnancy and the presence
of significant fever. A great many patients who
have mild labile hypertension, with pressures of
about 150/100 mm. Hg, can be given this drug.

Ergotamine tartrate is the backbone of the treat-
ment of the individual headache attack.

It is better, of course, not to use analgesics, if
one can get by without them, for the milder
analgesics are not particularly effective, and those
that are strong enough to be effective are capable
of inducing addiction. Darvon seems to represent
the intermediate in effectiveness between the sal-
icylates and codeine, m the 32 and 65 mg. doses,
and this is a popular preparation largely, I be-
lieve, because it is new rather than because it is
effective. Codeine has the lowest addiction liabil-
ity of all the commonly-used narcotic analgesics,
and next to it is a drug which is used very seldom
— -and I don’t know why, for it has an analgesic
potency which resembles that of morphine and yet
its addiction liability is considerably less. It is
methadone. The dose is the same as that of mor-
phine; it can be administered by mouth; the rate
of development of tolerance is slow; and there are
occasional patients in real misery from this dis-
order for whom one must do something of this
sort.

There are patients who exhibit “status mi-
graine,” severe, prolonged headaches usually in
association with severe reactive depressions. They
sometimes must be hospitalized and do need po-
tent drugs. I think methadone is the safest of these
agents.

MIGRAINE PROPHYLAXIS

Now with respect to prophylactic agents. Again
reserpine, chlorpromazine and, in this case, mepro-
bamate do not fill the need. The tranquilizers are
not effective agents for preventing vascular head-
aches of the migraine type. Indeed reserpine
seems to increase the frequency with which they
occur. You may have had experience with using
reserpine in patients with hypertension, and have
found that they develop facial flush, stuffy nose
and a syndrome that resembles parasympathetic
hyperactivity. Many of these patients develop head-
aches that are physiologically quite similar to
those of the migraine type. Thus reserpine, chlor-
promazine, meprobamate and all the other agents
of this class are not particularly effective here.

Here again, whenever an “ivory-tower type”
talks to a group of men who must meet the prob-
lems of day-to-day medical practice, there are
always individual exceptions to everything that
he says. Perhaps there are occasional patients
who will benefit from some of these agents that
I have said are worthless for this purpose. Thus I
caution you that what I say is based on experience
with large groups of patients. I certainly would
not want to predict what might happen in an in-
dividual case, but there are decisions that have to
be made on the basis of what is in the literature,
and it is to these broad decisions that I have been
referring.

Now very recently there has come to be some
reason to believe that the pharmacopathologic

Vol. LII, No. 6

Journal of Iowa Medical Society

341

physiology of migraine is related to a local in-
crease in tissue serotonin. I understand that sero-
tonin and carcinoid had quite a go-around at these
meetings last year, so I shan’t talk about them at
all except to say that there may be an excess of
serotonin locally in migraine, and that as a pro-
phylactic agent a drug called methysergide or
U.M.L. appears to hold some promise as a pro-
phylactic agent in migraine. This agent is not ef-
fective when administered for a headache attack.
It is effective when it is administered three or four
times daily, in 2 mg. doses over a period of weeks,
for preventing the occurrence of headaches. It is
effective only prophylactically. Now it is not a re-
markable answer, for it appears to benefit only be-
tween 50 to 70 per cent of patients when taken
as a prophylaxis. But the people who get this
material are the “tough cases.” I have about 40
patients who never had received relief from any
other prophylactic agent over a period of several
years, and slightly more than half of them have
obtained real benefit from this drug. I believe
that this represents an advance in the prophylaxis
of migraine.

The toxic effects are usually upper-gastrointes-
tinal distress and some slight feelings of giddiness.
Among the several thousand cases that have been
so treated, there have been about six cases re-
ported with pathologic vasospasm in one or more
extremities. The vasospasm usually terminates
when the drug is stopped. It is not possible now
to foresee how much of a problem vasospasm will
be when methysergide is widely used.

OTHER TYPES OF HEADACHE

I intend devoting no more than about two
minutes to the two other commonest kinds of
headaches, for I have already dealt with them in
large part. The so-called “psychogenic headache”
is almost invariably either migraine or skeletal-

Just Like a Doctor's P

Candor requires an analysis of the too often
repeated slogan “just like a doctor’s prescription”
— which emphasizes compounding. A private sur-
vey of retail and hospital pharmacies tells us ex-
actly what a doctor’s prescription in 1962 is like.
It is not likely to be made up of more than one
ingredient. The pharmacists questioned were gen-
erally agreed that 75 per cent of the prescriptions
filled are single directives, and only 25 per cent
are compounded. One pharmacy estimated as high
as 90 per cent are for single items.

The trend, of course, has been away from the
shotgun to the high-speed rifle. “Just like a doctor’s
prescription used to be” more nearly expresses
the situation.

muscle-contraction headache. If it is not, it may be
a frank hysterical conversion symptom which has
no basis in pathologic physiology, and in a sense
the patient is putting on an act in order to gain
some objective, whether it be to get out of some-
thing or into something. But this is a relatively
uncommon kind of headache — one which has no
basis in disturbed physiology but is, in effect, a
complaint alone.

The last kind is the so-called post-traumatic
headache. Those headaches which occur after trau-
ma and which clear up within two, three, four or
five weeks usually are related to the effects of the
trauma. But the headaches which continue for
months or years after trauma usually are skeletal-
muscle-contraction headaches or migraine head-
aches. Less commonly, they may be a painful
neuroma or scar, and by palpating the scar or
examining the scalp carefully for neuromata, one
may be able to tell whether the cause is one or the
other. If novocaine infiltration relieves the pain,
you have achieved a diagnosis. This is the least
common of the post-traumatic headaches. As I
said, the most common are skeletal-muscle-con-
traction headaches and migraine headaches — the
same sorts that occur in people who haven’t been
bumped on the head. And the same principles of
treatment apply to these sorts of post-traumatic
headache as those which apply to the skeletal-
muscle-contraction and migraine headaches that
have no association with trauma.

CONCLUSION

I have tried to be honest with you in this dis-
cussion. There is a great deal that we don’t know,
and when I read about headache too often, I am
disturbed by people who write definite statements
and appear to have all the answers. We have only
a very few partial answers, and I think it is fair
and honest to indicate that such is the case.

scription— Used to Be

Why should doctors be dragged into this sales
pitch, anyway? If it is unethical for doctors to ad-
vertise, is it not just as unethical for doctors to be
advertised? Decency finally prevailed when actors
dressed in white coats and posing as doctors in
commercial presentations were removed from the
microwaves. Now let us strive to have all mention
of doctors removed from this great American folk-
way!

Every man is his own lawyer, billed as “just like
a lawyer’s brief” makes as much sense!

— From an editorial in the new york state
journal of medicine, 62:1567, (May 15) 1962

Peripheral Arterial
Occlusive Disease:

What Can the Surgeon Offer?

HAROLD LAUFMAN, Ph.D., M.D.

Chicago, Illinois

The lesions of peripheral arteries which are
amenable to surgical treatment include aneurysms,
occlusive disease, and the vasospastic disorders.
In this discussion, we shall limit ourselves to
arteriosclerotic occlusive disease. At the outset it
should be stressed that although the surgeon has
a good deal to offer in the operative treatment of
this lesion, his contribution to the care of these
patients is not always surgical. Just as important
is his decision as to which cases to operate upon
and which cases not to operate upon. Also, he
must know enough about the patient’s general
condition so that he does not overoperate.

The indications for surgery in the presence of
occlusive disease in the major vessels of the legs
include symptoms of intermittent claudication.
There may be adequate collateral circulation at
rest, or there may be a more severe ischemia with
rest pain, or a threatened viability as evidenced
by the appearance of ischemia and death of super-
ficial tissue. As a rule, when claudication is pres-
ent, the occlusive lesion is rather limited; and
when there is rest pain or death of tissue, the
lesion may be more diffuse and may be a combina-
tion of a number of occlusions from the aortoiliac
area to the more distal vessels.

SELECTION OF PATIENTS FOR SURGERY

There is no need for elaborate instrumentation
for measuring distal pulses. The simple expedient
of feeling for pulses in proper places is a highly
useful maneuver. The oscillometer is useful for
measuring the amplitude of pulses, particularly in
a patient who is obese or in whom it is difficult
otherwise to palpate the arteries.

When occlusive symptoms come on slowly, there

Dr. Laufman is a professor of surgery at the Northwestern
University Medical School. He made this presentation at the
Refresher Course of the Iowa Chapter of the American Acad-
emy of General Practice, in Iowa City during February,
19112.

are many things a physician can do which do not
involve surgery. These include the care, hygiene
and protection of the limbs. A person who is lim-
ited in his walking distance, can be taught to take
shorter steps and to walk more slowly. Such ma-
neuvers will often increase the claudication dis-
tance and convert an incapacitated individual into
a useful, wage-earning person. Supportive care
during this period has been subject to a great deal
of controversy. We have learned to place very
little faith in the short-acting vasodilator medica-
tions which are on the market today. However,
the short-term dilatation afforded by these medica-
tions may have some psychological value, and I
must confess that I do use them now and then for
some patients.

I think it is a mistake for every physician to
consider himself capable of doing arteriograms
and aortograms. These are specialized procedures
which carry with them a certain amount of risk,
and therefore should be done only in institutions
with specialized personnel to carry them out. Once
the patient is referred for possible surgical man-
agement, it is the surgeon’s responsibility to
evaluate the patient in terms of his overall gen-
eral condition before considering the possibility
of surgery. Arteriographic visualization of the
blood vessels is unquestionably the most precise
way of defining the pathologic anatomy preopera-
tively. However, these procedures are not to be
done indiscriminately, since in many instances sur-
gery can be undertaken either without angiog-
raphy, or the combined procedures of vascular
visualization and surgery can be done at the same
time in the operating room.

Of course, there is no need to do a translumbar
aortogram in the presence of pulsating femoral
arteries bilaterally. A femoral arteriogram will
certainly serve the purpose under these circum-
stances. Furthermore, there is no point in doing
an arteriogram at all if there are popliteal pulses
present in both limbs or if there are anterior and
posterior tibial pulses present at both ankles. As a
rule, if the occlusion is below the popliteal level,
very little can be done for the patient surgically.

The average age of symptomatic patients with
arteriosclerotic occlusive disease of the lower ex-

342

Vol. LII, No. 6

Journal of Iowa Medical Society

343

tremities is about 60 years; 80 per cent are males;
some 15 to 30 per cent are diabetic patients. Fifty
to 60 per cent of these patients survive five years,
whereas 60 to 75 per cent of the non-diabetics
survive five years; that is, they escape death from
any cause for this period of time. The low occlu-
sions yield only fair late surgical results. A low
occlusion is one in the area of the popliteal artery
or below. High occlusions, that is to say those in
the femoral artery or above, tend to yield better
late surgical results. In patients with severe pain
and/or gangrene due to high occlusion, we have
found that with proper management, amputation
can be prevented or delayed in at least 50 per cent
of this group.

| The selection of patients for direct surgery de-
pends upon the rate of progression of the symp-
toms or the degree of disability of the patient.
Patients who are selected for surgical therapy
fall, for the most part, into three categories: 1)
those with gangrene or severe rest pain; 2) those
with progressive claudication or skin changes;
and 3) those who consider themselves disabled by
their claudication. I do not consider a man dis-
abled who is able to carry on his usual functions
as an executive, but who complains that he cannot
play 18 holes of golf unless he uses a cart.

We find that some 32 per cent of the aortoiliac
type of occlusions require surgical treatment. Of
those at the femoral and popliteal levels, some 42
per cent are suitable for surgery, and of the com-
bined types, only 26 per cent are suitable for surgi-
cal correction. The term “combined types” im-
plies generalized disease, and it is only in the se-
verely disabled patient that we feel surgery is
indicated.

In aortoiliac occlusions, claudication of one type
or another exists in 90 per cent, impotence in 40
per cent, and severe ischemia in only 10 per cent.
Hypertension also exists in about 25 per cent of
these patients, and the same appears to be true
for visceral atherosclerosis.

RESULTS ACHIEVED BY SURGERY

What can one expect from surgery for aortoiliac
occlusion? When we do a sympathectomy alone,
there is little or no change in the claudication nor
in the impotence; but ulcers on the legs do tend to
heal, and the skin vascular supply is improved.
Best results in direct arterial surgery are obtained
in this group of patients. When either a vascular
graft or endarterectomy is done as a reconstruc-
tive procedure, 70 to 90 per cent of patients with
aortoiliac occlusions obtain an excellent result.
There is said to be a 2 to 6 per cent operative
mortality, but our mortality is less than half of
this figure, probably because of extreme care in
our selection of cases. There may be some recur-
rence of occlusion in these patients up to 2 to 5
years afterward. Many of these so-called recur-
rences are, in fact, femoral occlusions or occlusions
elsewhere in the main stem arterial system of the

leg which have progressed in this period of time
to a symptomatic type of occlusion.

Distal occlusive disease occurs together with
aortoiliac occlusion in some 25 to 30 per cent of
patients. The surgical mortality is, in general, a
little higher in this group because the surgery is
more extensive. The percentage of immediate ex-
cellent and good results is somewhat less than it
is in bifurcation disease alone. When combined
occlusive lesions occur together, we find that some
50 to 70 per cent of patients obtain good results
following reconstructive surgery. Some of the
reasons for this fact are now understood as a re-
sult of more precise methods of diagnosis. For
example, if one operates upon a patient for bi-
furcation or iliac artery disease, it is a good policy
to do distal arteriograms on the operating table,
if need be, at the time of the operation, in order
to determine the patency of the distal stems. Many
times it is possible to correct all of the occlusions
at the same sitting. For example, it might be
feasible to do an endarterectomy in the iliac artery
and a bypass graft in the femoral artery.

SUBSTITUTE VESSELS

Homografts. In the past three or four years, we
have abandoned the use of homografts because of
the widely known fact that arteriosclerotic de-
generation occurs quite readily in such grafts
within a year or two after they have been im-
planted.

Plastic Prostheses. In vessels the size of the
common iliac artery or larger, the plastic pros-
theses are generally considered satisfactory. These
include the dacron or teflon fabric tubes. However,
failures of suture lines in the abdominal aorta and
rupture into the abdominal cavity and/or intestine
have been reported. It has been intimated that
these suture-line separations probably represent
a failure of the graft to establish a sufficiently firm
fibrous tissue bond with the host artery, and the
fine silk sutures must carry the load of the ar-
terial pressure. It has been found that fine silk
deteriorates, losing up to 90 per cent of its strength
within a year. For this reason, dacron sutures are
being used in aortic anastomoses, especially when
a prosthesis is inserted. The neointima which is
laid down in a prosthetic device is known to un-
dergo degeneration, with atherosclerotic changes
and mural thrombi, in precisely the same way
these phenomena occur to host vessels and in
other forms of grafts, but at a somewhat slower
rate. This observation is an interesting contribu-
tion to the knowledge of the etiology of athero-
sclerosis, insofar as it indicates that the degenera-
tive change is influenced by the blood flowing
past the lesion, and is not necessarily a tissue de-
generation of the wall itself.

The grafting of vessels below the inguinal liga-
ment, that is, of vessels smaller than the iliac
artery, presents problems when plastic prostheses
are used, although such prostheses still are used
when they are the only kind available. The prob-

344

Journal of Iowa Medical Society

June, 1962

lem, apparently, arises from a tendency of the
prostheses gradually to become encased in an in-
elastic scar tissue which leads to kinking and
stiffening at the anastomoses, particularly when
the flexion of joints demands a contraction and
stretching of the graft. The development of the
crimping principle did not do away with this
tendency, since all plastic woven and knitted grafts
tend to become stiff once they have been implanted
for any period of time. Most vascular surgeons
who have experienced this difficulty with many
plastic prostheses implanted from the inguinal
ligament down to the area of the popliteal artery,
can only wonder at the high long term success
rate still being reported by one group in this
country.

Autogenous Vein Grafts. The saphenous vein is
particularly well suited for end-to-end or bypass
grafts in the lower extremities. There appears to
be a much lower late occlusion rate — somewhere
around 20 per cent after two years— when veins
have been used for this purpose, as compared with
a 40 to 50 per cent reocclusion rate in the same
length of time when plastic prostheses have been
used. The saphenous vein is removed at the time of
the grafting operation, its branches are tied off, and
it is inserted upside down, so that occlusion will
not occur at the sites of its valves. Recently an-
other operation has been reported, though we
have not yet used it, in which the saphenous vein
is left in situ, but disconnected at its top and bot-
tom, and anastomosed to the side of the femoral
artery above and below the occlusion. As the
blood is allowed to flow through it, its branches
are tied and its valves are excised, and an end-to-
end anastomosis is made at each of the two or
three places where such valves occur.

Thromboendarterectomy. This operation has
been alternately condemned and condoned over
a considerable period of time. After having been
utilized many years ago by Leriche, Kunlin, and
Dos Santos, it was revived in this country by
Wylie, Barker and Cannon, and Warren. Many of
the generalities which have been published about
endarterectomy do not necessarily conform with
the experiences of all surgeons. However, both the
immediate and long-term results of thrombo-
endarterectomy, like those of other reconstructive
operations, are better in the larger vessels than in
the smaller arteries. One generality which has
been repeatedly stated is that thromboendarterec-
tomy is more suited to short occlusions than it is
to the more extensive type. However, in recent
years, we have applied thromboendarterectomy to
long occlusions, particularly in our limb-salvage
operations, and we have achieved a gratifyingly
high salvage rate. I shall say more about this in
a moment. Early failures are commonly due to
sluggish blood flow, either from distal disease or
the presence of flaps or shreds allowed to remain
on the lining of the vessel. Our success rate with
endarterectomy has improved considerably since
we began paying meticulous attention to these

details. Furthermore, the use of the patch graft
at the site of the arteriotomies and the careful
tacking down of the remaining intima distal to
the thromboendarterectomy have aided in the
smooth flow of blood. We find reports in the liter-
ature that there is a 23 per cent thrombosis rate
during the first year after initial success, with no
subsequent closures up to a year and half after-
ward. In our own experience, we find the percent-
ages somewhat comparable. Our early failure
rate in what we call “ripe” lesions, that is, those
which separate easily, is no more than 15 per cent.
Our late rate of occlusion is somewhat higher than
that reported, insofar as it is an additional 10 per
cent occlusion up to four years. It is also possible
that some of these occlusions occur at the site of
injury from controlling clamps rather than in the
endarterectomized segment itself. Long patches of
vein sutured to an open endarterectomized artery
is also a useful technic. Since Edwards described
this method, we have utilized variations of it with
success.

"DESPERATION" ENDARTERECTOMY FOR LIMB SALVAGE

“Desperation” endarterectomy is applied to pa-
tients who are in danger of losing a limb. The en-
darterectomy must be extensive because of the
absence of distal lumina. In these patients, the
surgery is undertaken with the full realization by
both patient and surgeon that in the event of fail-
ure, amputation may be hastened to a slight ex-
tent. However, inasmuch as limbs in this category
are either functionally useless or to some extent
a hazard to health, the risk of limb-loss resulting
from surgical failure is the understood price for
a possible restoration. This concept, of course,
cannot apply to patients who retain some measure
of useful function of their limbs. In other words,
the surgery is undertaken only if the patient is
in sufficient distress to warrant a drastic approach.
These limbs are afflicted with either chronic or
progressive ischemic ulceration, severe rest pain,
and/or gangrene of the toes or a portion of the
foot.

In a series of some 40 of these patients, we have
salvaged patency in 18 patients, or 45 per cent.
It is to be understood that without the operation,
these patients would either have had to undergo
amputation or would have had to live under the
influence of narcotics. It has now been almost
three years since we started doing this procedure,
and we have had a very low recurrence rate ne-
cessitating amputation. Of our 18 initial successes,
only three have come to amputation since the
initial success. In other words, these patients have
been granted a two- or three-year respite during
which they have been able to retain a limb which
otherwise would have undergone amputation.

SYMPATHECTOMY

It is our policy to perform lumbar sympathec-
tomy either as a preliminary or a concomitant pro-
cedure in all patients appearing to be amenable

Vol. LII, No. 6

Journal of Iowa Medical Society

345

to arterial reconstruction. Also, it is used as a
definitive procedure when reconstruction appears
improbable. In these patients, the sympathectomy
often results in sufficient improvement to carry
the patient for a considerable period of time and
in many instances for the remainder of his life.
If only limited or negligible improvement follows
the sympathectomy, the patient may eventually
reach the stage at which he may be considered a
candidate for direct surgery or desperation en-
darterectomy. If, as occasionally occurs, we can
predict only limited success from a sympathec-
tomy, and if the patient’s lesion is, in our judg-
ment, amenable to more extensive surgery, the
endarterectomy is done at the same sitting. When
bypass procedures are done, the operations of
sympathectomy and bypass are usually done at
the same sitting. It is difficult to predict which
patients will do better with sympathectomy alone.
A large number of our patients who we believe
would otherwise have had severe symptoms re-
cover sufficiently to regain useful life after sym-
pathectomy alone. Poorest results from sympathec-
tomy occur in patients with small-vessel disease as
it is encountered in diabetes. Best results appar-
ently occur in patients who have already devel-
oped extensive collateralization, and in these in-
stances the sympathectomy dilates the collateral
vessels to an extent sufficient to give them func-
tional, useful limbs. We do not believe that sympa-
thectomy actually worsens the condition. The few
instances in which amputation has been necessary
after sympathectomy have been instances in which
either the blood pressure had dropped sufficiently
during the operation to precipitate arterial throm-
bosis, or in which a plaque had broken off from
the aorta or iliac artery during a procedure and
was carried distally as an embolic occlusion.

SUMMARy

I did not intend to present this material for the
purpose of teaching the technic of arterial surgery
to you. I am presenting it for only one purpose,
that is to inform you of what can be done and to
warn that, on the one hand, success cannot be ob-
tained in every case, and yet, on the other, that
there is a gratifying precentage of patients who
can obtain relief from surgery.

One of the most important aspects of treatment
of peripheral arterial disease is still the conserva-
tive care that the family physician can give to
the patient with occlusive arterial disease of the
lower extremities. In the presence of good care —
and this includes management of other infirmities,
such as diabetes, hypertension, heart disease, etc —
the progress of the occlusive lesion can often be
retarded or arrested. If it cannot be stopped and
if symptoms progess, then something specific can
usually be done by the surgeon.

As I have indicated, I do not believe in sub-
jecting every patient with evidence of occlusive
disease to aortograms or arteriograms or other
involved diagnostic procedures. Provided a care-

ful protocol is kept of meticulous physical ex-
amination, and provided the patient is subjected
to conscientious, devoted care, it is surprising how
much improvement one can obtain with conserva-
tive measures, and how gratifying the results can
be with this type of management.

AMA and Chest Physicians Plan
Joint Session in Chicago

The American Medical Association and the
American College of Chest Physicians will hold a
combined scientific session at McCormick Place,
Chicago’s new convention center, on Monday,
June 25. This will be the closing day of the Chest
Physicians’ five-day meeting which will have its
headquarters at the Morrison Hotel in Chicago.
Also, it will be the opening day of the American
Medical Association’s annual meeting. Arthur M.
Master, M.D., New York, chairman of the AMA’s
Section on Diseases of the Chest, will deliver the
opening address at the joint meeting. His topic
will be “Fads and Public Opinion in Heart Dis-
ease.”

The program will include a symposium on “Re-
sults of Surgical Treatment of Acquired Cardio-
vascular Disease” with Drs. Frank Gerbode, San
Francisco; Donald Effler, Cleveland; Dwight E.
Harken, Boston; E. Stanley Crawford, Houston;
and Ralph A. Deterling, Jr., Boston. A second
symposium on “Special Contributions in Chest
Diseases” will feature as participants Drs. Theo-
dore H. Noehren, Buffalo; Oscar H. Friedman,
Stanley M. Blaugrund and Louis E. Siltzbach, New
York; Morris Wilburne and Josh Fields, Los An-
geles.

There will also be six round table luncheon dis-
cussions on various types of emergencies encoun-
tered in dealing with diseases of the chest. Mod-
erators will be Drs. William F. Miller, Dallas;
Eliot Corday, Los Angeles; Irving Mack, Chicago;
Frederick H. Taylor, Charlotte, North Carolina;
Peter Safar, Pittsburgh; and Roy F. Goddard, Al-
buquerque.

The AMA’s Sections on Anesthesiology, Pathol-
ogy, and Physiology will join with the Chest Physi-
cians for the afternoon section of the meeting to
conduct a symposium on “Inhalation Therapy.”
Robert D. Dripps, M.D., Philadelphia, will moder-
ate.

The always popular Fireside Conferences, long
a feature of the Chest Physicians meetings, will
again be part of the joint meeting with AMA.
These will be held at the Morrison Hotel on Mon-
day night, June 25. Among the topics to be in-
cluded in the thirty round table discussion ses-
sions are: Bronchial Carcinoma, Allergic Bron-
chitis and Allergic Pneumonitis, Screening Tests
for Emphysema, Indications for Cardiac Surgery
in the First Year of Life, Impending Myocardial
Infarction, Esophageal Problem Cases, and The
Smoking Controversy.

Experience With Metronidazole,

A New Trichomonacide

JOHN E. KRETTEK, M.D.
Council Bluffs

Trichomonas vaginalis generally is regarded as
the most important etiologic factor in leukorrhea.
The high incidence of this infection in the United
States is indicated by the estimate that one of
every five women has trichomoniasis.1 The wide
variety of therapeutic programs for treatment of
trichomoniasis may reflect the difficulty currently
encountered in controlling this infection. If this
assumption is correct, it is obvious that a simple
form of treatment that carries an excellent assur-
ance of success will be welcome and is needed.

The well-known English surgeon Stanley Way,
in speaking of new operations for cure of stress in-
continence, once remarked that the procedures of
which he spoke all have one thing in common —
namely, that their originators all claimed good re-
sults. Similar claims for methods of treating tricho-
moniasis have been the rule and have clouded the
approach to therapy. Treatments recommended
have ranged from pantry-shelf items such as salt,
sugar or vinegar, at one extreme, to psychother-
apy at the other. In 1954 and again in 1956, Moore
and Simpson2- 3 recommended a method of treat-
ment combining local measures and “superficial
psychotherapy” based on the concept that tricho-
monal vaginitis is “essentially psychosomatic in na-
ture”— that Trichomonas vaginalis is “incapable of
producing symptoms except in a vaginal tract con-
ditioned by emotional disturbances.” As recently
as 1959, McEwen4 concluded, on the basis of his
observations in 92 cases of trichomonal vaginitis,
that “failure to cure a patient is not due to drug
failure or reinfection by a sexual partner, but is
more probably due to an inability to change chron-
ic emotional disturbance.”

Rational approach to definitive therapy has
been advanced considerably by studies identifying

Dr. Krettek is associated with the Cogley Clinic, in Council
Bluffs, and is a member of the staff in obstetrics and gyne-
cology at the Creighton University Medical School. This paper
is adapted from a presentation he made at the Omaha Ob-
stetrical and Gynecological Society on September 20, 1961.

Flagyl® brand of metronidazole was supplied for clinical
investigation through the courtesy of the Department of
Clinical Research of G. D. Searle & Co., Chicago.

the male as the principal source of reinfection,
such as those reported by Perl et al.5 in 1956. In
Perl’s initial studies, each woman having tricho-
moniasis was told to bring fresh urine from her
husband. The urine was centrifuged immediately
and the sediment examined by smear and culture
from trichomonads. Of the 36 specimens examined,
only one was positive (2.7 per cent). Questioning
the dependability of this method, these investi-
gators then examined semen instead of urine. The
wife was asked to bring in a semen specimen
masturbated directly into a sterile jar, and the
whole seminal specimen was cultured. When semen
specimens from husbands of 48 patients heavily in-
fected with Trichomonas vaginalis were examined
in this way, 28 (or 58 per cent) were found posi-
tive for trichomonads.

Investigation of the male by culturing the semen
for Trichomonas vaginalis has been an important
corollary to modern therapy of trichomoniasis.
Unless one considers the coital partner and treats
the infection in him, no cure in the female can
be assured. It is likewise obvious that trichomoni-
asis is essentially a venereal disease, the usual
method of infection being sexual contact. As with
gonorrheal vulvovaginitis of childhood, it is freely
conceded that occasional instances of trichomonal
infection by means of nonsexual personal contact
or by fomites may occur.

This paper is a preliminary report on our ex-
perience to date with a new trichomonacidal agent,
metronidazole, available for investigation under
the name “Flagyl.”

PHARMACOLOGY

The descriptive formula of metronidazole is
l-(B-hydroxethyl)-2-methyl-5-nitroimidazole. It is
a synthetic compound consisting of pale yellow
crystals that are slightly soluble in water, alcohol
and organic solvents. It is readily absorbed from
the intestinal tract.

Pharmacologic studies6 have demonstrated the
potency and nontoxicity of Flagyl. Tests for in vitro
potency (method of Sorel7) showed that a con-
centration of as little as one part Flagyl in 400,-
000 will destroy 99 per cent of a standard culture
of Trichomonas vaginalis in 24 hours. Tests for in
vivo potency in mice (method of Lynch et al.8)

346

Vol. LII, No. 6

Journal of Iowa Medical Society

347

showed that Flagyl given orally in a dosage rep-
resenting only 1/200 of the maximal tolerated
dose will give complete protection against Tricho-
monas vaginalis injected subcutaneously. Acute
toxicity studies in mice (by stomach-tube admin-
istration of Flagyl in aqueous suspension) demon-
strated an unusually high order of therapeutic
safety. The LDg0 by this method was found to
be greater than 3,250 mg. per kilogram of body
weight — a dose equivalent in the human to some
195,000 mg. The usual daily dose of Flagyl in
humans is 500 mg. when only an oral or a vaginal
course is given, and 1,000 mg., when oral and
vaginal therapy are given concurrently. Results
of subacute and chronic toxicity studies in rats
and dogs have shown comparable ranges of thera-
peutic safety.

EARLY CLINICAL STUDIES

Early observations on the efficacy of Flagyl in
the treatment of trichomoniasis conducted in
France, England and Canada have now been fully
corroborated in the United States. All of these
studies indicate that the drug justifies a very high
expectancy of cure, can be administered orally,
ordinarily requires but 10 days of treatment, and
is associated with a low incidence of non-serious
side effects.9-14

Though Flagyl is not yet commercially marketed
in the United States, at least 40 reports have ap-
peared in the foreign medical literature describing
clinical experiences with it. Flagyl has been sub-
jected to clinical trials in this country since Octo-
ber, 1959. Preliminary opinions of investigators
in this country have been characterized by most
unusual enthusiasm. For instance, after treating 149
women and 99 men, Holmstrom15 reported: “On the
basis of our experience to date, we can say that
Flagyl appears to be the most effective therapeutic
agent ever introduced for the treatment of trich-
omonal vaginitis. The combination of vaginal
suppositories for the female patient plus oral ad-
ministration for the female and her sexual partner
gives the best results. The drug is well tolerated
and accepted by the patient. Side effects are min-
imal, temporary, and not troublesome.”*

METHOD

In our study, diagnosis in each patient was con-
firmed by examination of a fresh saline suspen-
sion of the vaginal washings. No patient with a
doubtful microscopic diagnosis was included in
the study, nor was any patient treated on clinical
findings alone. All patients with the diagnosis of
trichomonal vaginitis in this study were consecu-

* After treating some 600 patients, Holmstrom has concluded
that “oral administration of Flagyl to both sexual partners
appears to be the most effective method yet developed for
eradicating Trichomonas vaginalis.” (From “Trichomonal
vaginitis treated svstemically : New trichomonacidai agent
for oral and topical administration,” to be published.)

five and unselected. Diagnosis and follow-up of
each patient were personally verified.

In each case the male partner (when one ex-
isted) was treated orally, the importance of this
factor being carefully explained to the female
partner. This study does not deal with the male
aspect of the problem, although certain parallel
studies in this regard are in progress.

In this study, 250 mg. tablets of Flagyl were
used for oral administration, and 500 mg. vaginal
inserts for local application. Identical 250 mg. tab-
lets were administered orally, morning and night,
for 10 consecutive days to the patient and to her
consort. Simultaneously with this oral program,
the patient was furnished with and instructed to
introduce a 500 mg. vaginal insert nightly on re-
tiring. Vaginal douching was discouraged during
the period of therapy, but marital relations were
sanctioned. Managements of pregnant and non-
pregnant patients were identical.

Re-examination, including saline suspension of
the vaginal secretion, was carried out in each case
approximately 10 days following completion of
therapy, and when feasible at monthly intervals
thereafter. At least one monthly follow-up exam-
ination has now been made for each case.

RESULTS

Our study is still in progress and this report is
of a preliminary nature. At this date, records of
55 patients treated and of 47 male consorts given
concurrent oral therapy are available for analysis.
The shortest follow-up time is one month; the
longest is 11 months.

In 165 follow-up examinations including micro-
scopic examination of the vaginal secretion, there
has been 100 per cent freedom from trichomonads.
Concurrent abatement of symptoms reasonably
associated with this type of vaginitis has been
uniform and consistent with the disappearance of
the organisms from the vaginal secretion.

No instance of microscopic recurrence or re-
infection has been noted in any patient to the
present time. Six of the 55 patients were treated
in various stages of pregnancy, and five of these
have been re-examined on one or more occasions
in the postpartum period.

In the entire group, the only side effect was a
single instance of a mild erythematous eruption
on both lower extremities. This was not sufficient-
ly severe to warrant interruption of therapy, and
subsided spontaneously after completion of ther-
apy. Gastrointestinal disturbances did not occur
in any patient in this series.

Post-therapy white blood cell counts have been
studied in 10 patients, and no aberrations have
been detected. Additional studies in this regard
are in progress.

In our opinion, our clinical success has been
completely gratifying.

348

Journal of Iowa Medical Society

June, 1962

SUMMARY

A new trichomonacide, metronidazole (Flagyl)
has been administered concurrently to 55 female
patients with microscopically-confirmed tricho-
monal vaginitis and to 47 male consorts. Both part-
ners took the drug orally for 10 days. In addition,
the female patients used vaginal inserts nightly
during the period of oral therapy. All patients
have now been followed for at least 1 month,
and some for as long as 11 months.

Clinical remission of symptoms has paralleled
microscopic disappearance of trichomonads in all
cases.

REFERENCES

1. Kuder, K.: Vaginal infections. J. Amer. Med. Worn.
Ass., 5:173-179, (May) 1950.

2. Moore, S. F., Jr., and Simpson, J. W.: Emotional com-
ponent in Trichomonas vaginitis. Amer. J. Obst. Gynec.,
68:974-980. (Oct.) 1954.

3. Moore, S. F., Jr., and Simpson, J. W.: Trichomonal
vaginitis: Emotionally conditioned symptom. Southern Med.
J., 49:1495-1501, (Dec.) 1956.

4. McEwen, D. C.: Common factors in Trichomonas

vaginitis (Proceedings of the First Canadian Symposium on
Non-Gonococcal Urethritis and Human Trichomoniasis,
Montreal, 1959). Gynaecologia, 149 (Suppl.) :63-69, 1960.

5. Perl, G., Guttmacher, A. F., and Raggazoni, H.: Male
and female trichomoniasis: Diagnosis and oral treatment.
Obstet. Gynec. (NY), 7:128-136, (Feb.) 1956.

6. Unpublished data, Division of Biological Research,
G. D. Searle & Co.

7. Sorel, C.: Trois techniques de recherche du “Trichomonas
vaginalis”; leurs valeurs comparees. Presse Med., 62:602-
604, (Apr. 21) 1954.

8. Lynch, J. E., Holley, E. C., and Margison, J. E.: Studies
on use of mouse as laboratory animal for evaluation of
antitrichomonal agents; action of 21 agents. Antibiot.
Chemother. (Wash.), 5:508-514, (Sept.) 1955.

9. Durel, P., Roiron, V., Siboulet, A., and Borel, L. J.:
Systemic treatment of human trichomoniasis with derivative
of nitro-imidazole, 8823 R.P. Brit. J. Vener. Dis., 36:21-26,
(Mar.) 1960.

10. Fortier, L. : Traitement de la trichomonase chez la femme
par un nouveau derive de l’imidazole (Proceedings of the
First Canadian Symposium on Non-Gonococcal Urethritis and
Human Trichomoniasis, Montreal, 1959). Gynaecologia, 149
(Suppl.) : 158-164, 1960.

11. Medical Society for the Study of Venereal Diseases:
Systemic treatment of Trichomonas infestation. Lancet, 1:-
1226-1227, (June 4) 1960.

12. Robinson, S. C.: Observations on vaginal trichomoniasis.

I. In pregnancy. Canad. Med. Ass. J., 84:948-949, (Apr. 29)
1961.

13. Sylvestre, L., and Gallai, Z.: La trichomonase uro-
genitale masculine et feminine. Un. Med. Canada, 89:735-
741, (June) 1960.

14. Watt, L., and Jennison. R. F: Clinical evaluation of
metronidazole: new systemic trichomonacide. Brit. Med. J.,
2:902-905, (Sept. 24) 1960.

15. Holmstrom, E. G.: Investigator’s clinical report, August

II. 1960.

Isolation of Histoplasma capsulatum,

Allescheria boydii and
Microsporum gypseum From Iowa Soil

In an Attempt to Determine the Probable Point Source
Of a Case of Histoplasmosis

JOHN CAZIN, JR., Ph.D.

WILLIAM F. McCULLOCH, D.V.M., M.P.H.
and JOHN L. BRAUN, M.S.

Iowa City

The etiologic agent of histoplasmosis has been
known since 1932, 2- 10’ 11 but only since the
studies of Palmer17 and Christie and Peterson,1 in
1945, has Histoplasma capsulatum been recog-
nized as a frequent infectious agent for man. For
many years, the few reported cases of histoplas-
mosis were usually recognized on postmortem ex-
amination. Thus investigators were led to believe
that the infection rarely occurred, but that when

Dr. Cazin is a member of the SUI staff in bacteriology, and
Dr. McCulloch and Mr. Braun are members of the staff of the
Institute of Agricultural Medicine at SUI.

it did take place it was invariably fatal. We are
now aware that histoplasmosis occurs commonly
in a benign form that usually results only in pos-
itive skin sensitivity to histoplasmin and residual
calcification at the primary focus of infection.

During the past half-century, a number of rec-
ognized pathogenic fungi have been isolated from
various natural sites. They have been shown to
be present in decaying vegetative material, and
in domestic and wild animals, and some have been
shown to exhibit a saprophytic existence in soil.4
It has been established that fungus infections of
the systemic type are not generally transmitted
from man to man or from animal to man. How-
ever, since the infectious organisms may occur as
saprophytes either on decaying vegetative matter
or in soil, it is not difficult to visualize how spores
from the organisms may enter the body either
through inhalation of contaminated air or by acci-
dental implantation during a puncture wound of
the skin.

Vol. LII, No. 6

Journal of Iowa Medical Society

349

Further epidemiologic considerations of mycotic
infections will be limited to histoplasmosis, since
in this particular study we are interested in a case
of histoplasmosis that occurred in a six-month-old
Iowa infant. Furcolow7 has recently published an
excellent study on the epidemiology of histoplas-
mosis in which he points out the possible correla-
tion of histoplasmin sensitivity with certain cli-
matic conditions. He was able to show that areas
of high histoplasmin sensitivity generally are in
regions where the average summer temperatures
range from 70 to 80°F., and the average annual
precipitation varies from 35 to 50 in. Presumably
those conditions are most suitable for the success-
ful existence of H. capsulatum in nature.

The incidence of histoplasmosis is determined by
the exposure of susceptible individuals to the or-
ganisms that occur as saprophytes in nature.
H. capsulatum was first isolated from soil by Em-
mons3 in 1949. Subsequently, the organism has
been isolated from a number of different sites
throughout the world.19 Even though the organism
has been isolated repeatedly from a large number
of wild and domestic animals,6’ 16 Emmons does
not believe that they are responsible for the
endemicity of the mycosis. Rather, he thinks that
in certain endemic areas the organism exists as a
part of the saprophytic soil microflora and that
both man and animals are infected from that
source.

In a geographical mapping of the histoplasmin
sensitivity of human beings in the United States,14
it was found that the percentage of reactors in
Iowa ranged from 70 per cent positive reactors
along the southern border of the state to 2 per
cent in the northern third of the state. Other
studies have shown that infections due to H. cap-
sulatum probably occur as a result of a susceptible
individual’s coming into close contact with a focus
of fungus growth in nature.9 In view of the high
histoplasmin-reaction rate, it must be assumed
that a fairly large number of potential foci of
infection exist in Iowa. Thirty-eight cases of histo-
plasmosis in human beings were reported in Iowa
in 1961. 12 Our report is concerned with data ob-
tained as a result of epidemiologic and laboratory
follow-up studies on one of the cases. The disease
occurred in a six-month-old white female who
was admitted to the State University of Iowa Gen-
eral Hospital on January 15, 1961, manifesting
primarily a profound anemia, hepatosplenomegaly,
mild diarrhea, vomiting and fever. Requests for
isolation of fungi from this patient were first made
after the surgical removal of the spleen. H. capsu-
latum was isolated from the spleen, and subse-
quently from the bone marrow and blood.

A VISIT TO THE EPIDEMIOLOGIC SITE

A visit was made to the residence of the patient,
extensive questioning of the family was conducted,
and appropriate soil specimens were obtained for
cultural studies. The following pertinent informa-
tion was obtained.

L. M. W. (SUI 61-765) was an only child who
resided, following her birth on July 10, 1960, on a
small southeastern Iowa farm with her mother and
father. The parents had moved there in February,
1960. The clinical history of the patient was es-
sentially negative up to the onset of the illness, on
approximately December 25, 1960. The farm resi-
dence consisted of a four-room, one-story structure
with no basement. A well on the premises pro-
vided the water supply, and the toilet facilities
were out of doors. In addition to the house, there
were several smaller buildings, snow fence and
corncribs on the farm. The grounds were sodden,
and numerous areas of poor drainage were in evi-
dence.

The farm animals included four milk cows, three
calves, six sows and 16 feeder pigs. These ani-
mals shared the same farm lot and pasture area.
No dogs, cats or fowl had been housed on the farm
since its purchase in February, 1960. A sizeable
rat and mouse population was in evidence. Prior
to its use as a hog house, one of the farm buildings
had been used to house chickens. That building
had been cleaned in May, 1960, and the litter had
been discarded on the ground near the building.

The patient’s environmental contacts during the
probable exposure period had been limited to
the farm home, the farm of her paternal grand-
parents and the farms of a few neighbors. She had
been outdoors occasionally at the farm home. Ex-
posure potential at the other premises was limited
to the insides of houses and to the brief outside
exposure involved when she was carried to and
from automobile transport.

MATERIALS AND METHODS

The soil samples obtained on the premises con-
sisted of the following:

1. Soil and debris from the inside and outside
of a small doghouse near a clothesline where the
child had been with her mother on several occa-
sions

2. Ledge dust, old sparrow feces, etc., from an
old chicken house now used for the hog house

3. Soil sample from inside the old chicken house
(No. 2, above)

4. Soil and manure sample from the hog yard
where most of the chicken manure from the May
19, 1960, cleaning had been scattered

5. Composite taken from inside of the tractor
shed-barn combination (Sample consisted of soil,
old hay and manure)

6. Moldy or damp hay and soil from the old hay
shed, and soil from inside near the edge of the
same building

7. Soil and debris from the edge of the corn-
crib and an old, rotten lumber pile

8. Soil from the outside edge of the hay shed
described in No. 6, above

9. Soil and debris from inside of the washroom
and milk-separator room, approximately 15 ft,
north of the house

350

Journal of Iowa Medical Society

June, 1962

10. Composite sample of house dust from the
tops of door ledges, etc.

In an attempt to isolate pathogenic fungi from
specimens obtained at the suspected focus of in-
fection, the method used was essentially that of
Emmons,5 with slight modifications. Specimens
were collected in 100 ml. wide-mouth, screw-cap
bottles which were kept tightly closed except
when samples were removed. The specimens were
stored at room temperature. Because insufficient
material was available, specimens 9 and 10 were
combined, and allowances were made for pro-
portionate volumes throughout the following pro-
cedure.

Approximately 10 ml. of each specimen was
transferred to a large test tube, and 25 ml, of
physiological saline was added. A rubber stopper
was inserted in the tube, the mixture was shaken
vigorously for five seconds, and then it was al-
lowed to sediment. After it had stood for 15 min-
utes, 4 ml. of the uppermost supernate was pipet-
ted into another tube containing 1 ml. of antibiotic
solution to provide a final concentration of 2 mg.
streptomycin and 5 mg. penicillin per milliliter.
Each of four albino mice was injected intraperi-
toneally with 1 ml. of the mixture and held for
four weeks. The liver and spleen of each mouse
was then removed for culture onto Sabouraud’s
slants, mycosel slants and blood agar plates. Dupli-
cate sets of media were inoculated for incubation
at 37° and 25°C. All media were held for one
month before being discarded as negative.

Besides the attempt to isolate pathogenic fungi
by selective infection of a susceptible experimental
animal, attempts were also made to isolate the
organisms by direct inoculation onto a selective
medium. Mycosel agar plates were streaked with
varying amounts of the soil suspension supernates
and incubated at 25 °C. Those plates that were not
overgrown with saprophytic fungi were held for
up to one month before being discarded as nega-
tive.

RESULTS

From the eight individual and one combined
specimens examined, three different pathogenic
fungi were isolated: Histoplasma capsulatum, Al-
lescheria boydii, and Microsporum gypseum. The
distribution of organisms in the individual soil
samples and the number of infected animals
which were found in each experimental group are
shown in Table 1.

All attempts to isolate pathogenic fungi directly
on mycosel agar from these soil suspensions have
been unsuccessful. After specimen No. 1 had been
shown to contain H. capsulatum and M. gypseum,
repeated attempts to isolate these organisms by
the direct plating method on mycosel agar were
likewise unsuccessful.

DISCUSSION

Most people are not aware that the first success-
ful isolation of H. capsulatum from a case of

histoplasmosis was achieved at the State Univer-
sity of Iowa College of Medicine in 1932 by Dr.
G. H. Hansmann and Dr. J. R. Schenken.10' 11
Their investigations conclusively proved that the
causative organism was a diphasic fungus. Togeth-
er with Dr. George W. Martin, of the Department
of Botany, they classified the organism in the
genus Sepedonium.15 Even though Hansmann and
Schenken proved that their organism was a fun-
gus and successfully fulfilled Koch’s postulates,
their work has been overshadowed by that of De-
Monbreun,2 which is somewhat more complete.

It has been shown previously that H. capsu-
latum can be isolated from Iowa soil.8 This study
reemphasizes the fact that this organism may be
a somewhat common member of the saprophytic
soil flora in certain specific locations endemic for
histoplasmosis. This disease has been recognized
as an important frequent infection of man only
since 1945, yet it is currently estimated that more
than 30,000,000 people are infected with it in the
United States.19

Silverman et al.18 suggest that histoplasmosis
may constitute the most common cause of “fever of
undetermined origin” in childhood in the endemic
areas of the United States. The primary pul-
monary form of the disease must be differentiated
from the common cold, influenza and bronchitis.
The disseminated form must be differentiated
from neoplastic disease, leukemia, Hodgkin’s dis-
ease, tuberculosis, syphilis, leishmaniasis and the
other deep mycoses.13 Since about two-thirds of
Iowa is endemic for histoplasmosis, it is not un-

TABLE I

ISOLATION OF PATHOGENIC FUNGI FROM MICE
INJECTED WITH SOIL SUSPENSIONS

Soil

Specimen

Histoplasma

capsulatum

Fungi Isolated
Allescheria
boydii

Microsporum

gypseum

2/4*

0/4

1/4

0/0**

0/0

0/3

3/3

0/3

0/4

0/3

0/2

9/10

0/3

* The number of animals from which the particular organ-
ism was cultured over the number of experimental animals
that survived the 4-week incubation period.

** Where experimental groups were smaller than four
animals, death occurred within 72 hours after the mice re-
ceived the injection of soil suspension.

Vol. LII, No. 6

Journal of Iowa Medical Society

351

reasonable to assume that many cases of the dis-
ease go unrecognized simply as a result of its
protean manifestations.

In this particular study, a saprophytic reservoir
of H. capsulatum was discovered near the home
of the patient. Moreover, it was noted that the
child had been exposed on several occasions to
the particular site from which the organism was
isolated. Exposure to other potential environ-
mental infection sites had been extremely limited,
since the child was only six months of age.

Since the principal portal of entry for the fungus
causing histoplasmosis is considered to be the res-
piratory tract, it is possible that the child may
have inhaled airborne spores at any of a number
of places during her lifetime. Therefore, the area
associated with the unoccupied doghouse from
which H. capsulatum was isolated can only be
suggested as the probable point source of infec-
tion for this child.

It was also of interest that two other pathogenic
fungi, A. boydii and M. gypseum, were isolated
from the soil specimens examined in this study.
Both of those organisms have previously been
shown to have a saprophytic existence in soil.4
In this study, the organisms were recovered by
the mouse inoculation technic. Direct plating on
mycosel agar was unrewarding. Since these or-
ganisms were not of particular interest in this
study, specific selective isolation technics were
not employed.

SUMMARY

Epidemiologic and cultural studies have sug-
gested the probable point source of infection for
a case of histoplasmosis that occurred in a six-
month-old infant. In addition to Histoplasma cap-
sulatum, two other pathogenic fungi, Allescheria
boydii and Microsporum gypseum, were also iso-
lated from soil specimens obtained at the farm
on which the infant lived.

ACKNOWLEDGEMENTS

We are indebted to Dr. J. B. Roberts, of Ottum-
wa, who referred this case to the SUI General
Hospital, and to Dr. John Opitz, a former resident
in the SUI Department of Pediatrics, who was
the attending physician.

REFERENCES

1. Christie, A., and Peterson, J. C.: Pulmonary calcification
in negative reactors to tuberculin. Am. J. Pub. Health 35:-
1131-1147, (Nov.) 1945.

2. DeMonbreun, W. A.: Cultivation and cultural character-
istics of Darling’s Histoplasma capsulatum. Am. J. Trop. Med.
14:93-125, (Mar.) 1934.

3. Emmons, C. W.: Isolation of Histoplasma capsulatum
from soil. Pub. Health Rep. 64:892-896, (July 15) 1949.

4. Emmons, C. W.: Natural occurrence in animals and soil
of fungi which cause disease in man. Proceedings of Seventh
International Botanical Congress. 1950, pp. 416-421.

5. Emmons, C. W.: Significance of saprophytism in epi-
demiology of mycoses. Tr. New York Acad. Sc. 17:157-166,
(Dec). 1954.

6. Emmons, C. W.: Histoplasmosis. Pub. Health Rep. 72:-
981-988, (Nov.) 1957.

7. Furcolow, M. L. : Recent studies on epidemiology of his-
toplasmosis. Ann. New York Acad. Sc. 72 (No. 3) :129-163,
(Apr. 10) 1958.

8. Grayston, J. T., and Furcolow, M. L.: Occurrence of his-
toplasmosis in epidemics — epidemiological studies. Am. J.
Pub. Health 43:665-676, (June) 1953.

9. Grayston, J. T., Heeren, R. H., and Furcolow, M. L.:
Geographic distribution of histoplasmin reactors among
school age children within rural Iowa county. Am. J. Hyg.
62:201-213, (Nov.) 1955.

10. Hansmann, G. H., and Schenken, J. R.: New disease
caused by yeast-like organism. Science 77(Suppl, 2002) : 8,
(May 12) 1933.

11. Hansmann, G. H., and Schenken, J. R.: Unique infec-
tion in man caused by new yeast-like organism, pathogenic
member of genus Sepedonium. Am. J. Path. 10:731-738,
(Nov.) 1934.

12. Heeren, R. H.: Personal communication. 1961.

13. Lewis, G. M., Hopper, M. E., Wilson, J. W., and Plun-
kett, O. A.: Introduction to medical mycology. Chicago, Year
Book Publishers, 1958.

14. Manos, N. E., Ferebee, S. H., and Kerschbaum, W. F.:
Geographic variation in prevalence of histoplasmin sensitivity.
Dis. Chest 29:649-668, (June) 1956.

15. Martin, G. W.: Personal communication. 1961.

16. Menges, R. W., Furcolow, M. L., and Hinton, A.: Role
of animals in epidemiology of histoplasmosis. Am. J. Hyg.
59:113-118, (Jan.) 1954.

17. Palmer, C. E.: Nontuberculous pulmonary calcification
and sensitivity to histoplasmin. Pub. Health Rep. 60:513-520,
(May 11) 1945.

18. Silverman, F. N., Schwartz, J., Lahey, M. E., and Car-
son, R. P.: Histoplasmosis. Am. J. Med. 19:410-459, (Sept.)
1955.

19. Sweany, H. C.: Histoplasmosis. Springfield, 111., Charles
C Thomas, 1959.

S-R Foundation Starts Deluxe
Preceptorships

An experimental preceptorship program to ac-
quaint outstanding junior and senior medical stu-
dents with the elements of general practice work
in small communities will be sponsored in 1962
by the Sears-Roebuck Foundation in cooperation
with the Student American Medical Association
Foundation. This year’s pilot program calls for
locating eight medical students in communities
which have successfully participated in the Foun-
dation’s Community Medical Assistance Program.

Scholarships of $500 each will be given to stu-
dents who spend two consecutive months during
the current year studying and working with the
doctors in those communities. The townspeople
will provide board and room. Afterward, the stu-
dents will report their experiences in articles to be
published in the new physician, the periodical
issued by the Student AMA. The names of the
recipients were announced at the SAMA conven-
tion in Washington, D. C., in May, but too late
for inclusion here.

Since its inception in 1958, the S-R Foundation
has helped 54 communities throughout the country
secure the services of one or more physicians, and
it currently is endeavoring to get doctors for 18
towns. In Iowa, S-R projects have been successful
in several places, including Anthon, Cascade, Car-
son and Shelby, but the office buildings that the
organization assisted townspeople in erecting at
Farmington, Kimballton and Woodbine lack occu-
pants, and either one or two doctors are being
sought for the one under construction in Marcus.

State University of Iowa
College of Medicine

Clinical Pathologic Conference

SUMMARY OF CLINICAL FINDINGS

A 38- year-old teacher was admitted to the hos-
pital because of lung trouble, chills and fever,
and diarrhea. The patient had had episodes of
pneumonia at least once a year throughout his
life. During the previous two years, he had had
frequent respiratory-tract infections. He had al-
ways had digestive trouble, which he described
as a rapid transit of food through his gastroin-
testinal tract. Sometimes food particles had ap-
peared in the stool five hours after he ate the food.
Thi ■ee months before admission, the patient had
given up teaching because of chills, fever, sweats
and a cough productive of copio,us, purulent spu-
tum. He had been admitted to Oakdale Tuberculo-
sis Sanatorium. Studies for tuberculosis were
negative. During his twenties he had had numer-
ous operations on his sinuses. When he was 22
years of age, an appendectomy had been per-
formed upon him.

Physical examination revealed a thin, chronical-
ly-ill, 38-year-old white man in moderate distress
with coughing and dyspnea. His blood pressure
was 130/75 mm. Hg, his pulse rate was 115 per
minute, and his temperature was 102.2 °F. His
skin was warm and moist with sweat. His eyes
and ears were normal. His teeth were in poor re-
pair. His chest expanded fairly well, and the an-
teroposterior diameter was normal. There was
dullness at the left lung base, and there were
many fine crepitant rales at both bases. The pa-
tient was unable to expire rapidly. His heart was
normal to examination. The abdomen was flat and
soft, and the soft organs were not palpable.

The urinalysis was negative. The hemoglobin
was 10.9 Gm., and the white blood cell count was
23,200/cu. mm., with 86 per cent segmented neu-
trophils, 3 per cent band neutrophils, 3 per cent
eosinophils, 6 per cent lymphocytes and 2 per cent
monocytes. The stool was yellow in color and
watery in consistency. There was no blood in the
stool, but it was described as containing some
food particles. Pseudomonas aeruginosa was cul-
tured from the sputum.

In the posteroanterior and lateral x-ray films of

the chest, the heart and the great vessels were
within normal limits. An increase in the broncho-
vascular markings was present in both lower lung
fields, and some areas were suggestive of bron-
chiectasis. An area of pulmonary infiltration in the
right lower lung field suggested pneumonitis. The
electrocardiogram showed findings consistent with
an old anteroseptal myocardial infarction.

The vital capacity was 1,550 ml. (40 per cent of
predicted normal). The residual volume was 2,330
ml. (197 per cent of predicted normal). Severely
uneven distribution of inspired air was present.
The maximum breathing capacity was 42 L./min.,
the arterial oxygen saturation was 76 per cent, the
maximum expiratory flow rate was 47 L./min.,
and the arterial PC02 was 42 mm. Hg.

X-ray films of the sinuses showed chronic sinus-
itis involving the maxillary, frontal and ethmoid
sinuses.

The sweat chloride content was 94 mEq,/L., and
on a second occasion was 77 mEq./L. The one-
minute serum bilirubin was 0.2 mg./lOO ml., and
the 30-minute serum bilirubin was 1.0 mg./lOO ml.
A bromsulfalein test revealed 4 per cent retention
of the dye after 45 minutes. A cephalin floccula-
tion was 3+ at 24 hours and 4+ at 48 hours. The
zinc flocculation was 21 units. The blood urea
nitrogen was 7.0 mg./lOO ml., and the creatinine
was 1.0 mg./lOO ml. The whole blood C02 content
was 30 mEq./L., the sodium 134 mEq./L., the po-
tassium 5.0 mEq,/L., and the chlorides 99 mEq./L.
The total serum protein was 6.5 Gm./lOO ml., with
an albumin of 1.9 Gm./lOO ml., and a globulin of
4.6 Gm./lOO ml. The serum cholesterol was 96
mg./lOO ml. The alkaline phosphatase was 1.6
units.

The serum amylase was less than 50 units. The
serum carotene level was 2 micrograms per 100
ml. Duodenal juices were tested for tryptic ac-
tivity, and none was found.

During the first week after his admission, the
patient was given a soft general diet and was al-
lowed out of bed, given sedatives for sleep and
chloramphenicol, 250 mg., four times daily. After
one week, a saturated solution of potassium iodide,

352

Vol. LII, No. 6

Journal of Iowa Medical Society

353

10 drops four times a day, was started. On the
tenth hospital day, the patient was still quite ill,
and was coughing up large amounts of purulent
sputum. Chloramphenicol was then discontinued,
and Gantrisin, 1 Gm. every four hours, and
aqueous penicillin, 2.5 million units every 12
hours, were started.

The patient continued to get worse. He had high
fever. Much of the time he was drowsy and ob-
tunded. His respiratory infection did not respond
to therapy. On the twentieth hospital day, Poly-
mixin B, 25 mg. intramuscularly every six hours,
was started. On the twenty-eighth hospital day he
developed severe abdominal distention. Continu-
ous nasogastric suction was instituted. He con-
tinued to do poorly, and he died on the thirty-
second hospital day.

SUMMARY OF CLINICAL DISCUSSION

Dr. George N. Bedell, Internal Medicine: The
patient for discussion today is a 38-year-old school
teacher who had had a chronic illness throughout
most of his life. He entered this hospital with
what appeared to be a severe respiratory infec-
tion. His illness was exceedingly difficult to con-
trol, and after about a month of hospitalization, he
died.

The first speaker will be Mr. James Cole, who
will discuss the case from the students’ standpoint.

Mr. James Cole, junior ward clerk: The patient
is a 38-year-old man who had had both respiratory
infections and digestive trouble all of his life. The
latter consisted of diarrhea and noticeable food
particles in his stools. Initially, the respiratory-
tract infections consisted of at least one episode of
pneumonia every year, associated with severe
chronic sinusitis. In the last two years of his life,
chills, fever, sweating and a productive cough be-
came so severe that he was forced to quit teach-
ing school.

After reading the history and the results of lab-
oratory work as they had been presented to us,
we felt that his was a case of cystic fibrosis of
the pancreas, and we believe that everything list-
ed in the protocol can be explained on that basis.

The diarrhea was a manifestation of increased
bulk resulting from a deficiency of pancreatic
enzymes. There was no trypsin present in the duo-
denal juice, and though the protocol doesn’t con-
tain a record of a secretin test, we have been as-
sured that one was done with the patient in an
adequately stimulated state. We take this as an
indication of decreased pancreatic function.

He also had a low serum carotene level, which
is indicative of a malabsorption. We were unable
to find out whether there was any odor to his
stool. Both the serum chloride and sodium were
decreased, and this particular disease has been
listed as a cause of hyponatremia in children,
especially during the summer months.

The patient had a reversed albumin/globulin

ratio, and elevated cephalin and zinc flocculations
along with a low serum cholesterol. We felt that
all of these findings were consistent with malab-
sorption plus chronic infection. We did not find
any evidence of liver disease, especially since the
bromsulphalein, the one-minute bilirubin and the
alkaline phosphatase levels were all normal.

The electrocardiogram was interpreted as con-
sistent with an old anteroseptal myocardial infarc-
tion. Yet this man was 38 years old, had a serum
cholesterol of 96 mg./lOO ml., and had no history
of a clinical myocardial infarction. Also, we
understand, with right ventricular hypertrophy
secondary to a chronic lung disease, the R wave
may be absent in leads VI and V2, thus leaving a
Q wave which gives the picture of an old antero-
septal myocardial infarction.

A chest film was suggestive of bronchiectasis
and pneumonitis, but we didn’t think that it was
really a great help. A pulmonary function test,
however, revealed gross pulmonary involvement.
The values as they were given are those of chron-
ic emphysema. But we also note that his chest
expanded fairly well, and that the anteroposterior
diameter was not increased, which suggests some-
thing other than the common variety of emphy-
sema. The values as they have been presented
are similar to those that have been obtained in
fibrocystic disease of the pancreas occurring in
patients between 15 and 22 years of age.

Now we come to the sweat chloride determina-
tion. In reviewing the case, we thought that if we
were going to make this diagnosis, we had first to
show that the sweat chloride values were elevated
in the adult, just as they would be elevated in a
child, and secondly, that this disease might exist
in a 38-year-old man. We went into some of the
literature to substantiate these two points. Dr.
Charlotte Anderson1 has reported sweat chloride
levels using the mecholyl method of determina-
tion in several different groups of people, and her
values in normal adults are of particular interest
here. In 20 adults, in whom there was no disease
of any particular nature, as far as she could tell,
the values ranged from 19 to 82 mEq./L., with an
average of 52 mEq./L. Then she also determined
the sweat chlorides on 42 parents who had chil-
dren with fibrocystic disease, and found values
ranging from 10 to 84 mEq./L., with an average of
54 mEq./L. If we accept those values, we have
one determination of 94 mEq./L., which is definite-
ly elevated, and a second of 77 mEq./L., which is
on the upper border of normal.

As regards the possibility that the disease can
occur in an individual as old as our patient, we
found a case reported — again by Dr. Anderson —
in a 1960 issue of lancet.2 A 44-year-old man, in
whom Dr. Anderson felt that all the criteria neces-
sary to the diagnosis were met, had a lifetime
history of both bronchial infection and diarrhea.
Two of his cousins had died at 13 and 2 years of

354

Journal of Iowa Medical Society

June, 1962

age, respectively, with bronchiectasis and pneu-
monia. In this man, the submaxillary glands were
enlarged, the sweat chloride determinations were
85 mEq./L. and 71 mEq./L. There was no trypsin,
amylase or lipase in the duodenal secretion, and a
biopsy taken of the small bowel revealed numer-
ous goblet cells that were swollen and contained
large amounts of eosinophilic granular material.
Pulmonary function studies done on that man pro-
duced results similar to those reported here and
in children with fibrocystic disease. X-rays showed
diffuse mild bronchiectasis. Since Dr. Anderson’s
patient survived, there was no autopsy confirma-
tion.

We feel that the patient under consideration
today died a respiratory death secondary to
Pseudomonas pneumonia. Pseudomonas, along with
Staphylococcus, are the organisms most commonly
found in fibrocystic lungs. The terminal abdominal
distention that was noted could have been due to
any of a number of things, including bowel ob-
struction secondary to adhesions following ap-
pendectomy, or he could have had a perforated
peptic ulcer, a lesion that is being reported with
increasing frequency in association with some
chronic lung diseases. In recent articles, authors
are trying to show a marked increase in peptic ul-
cer associated with fibrocystic disease. The in-
formation in the protocol surely didn’t give us
anything to justify this diagnosis, but we felt that
it was also consistent with acute gastric dilatation
which is sometimes seen in terminal cardiorespira-
tory patients who are receiving nasal oxygen.

Another possibility that we thought had to be
considered was chronic pancreatitis coexisting
with some chronic suppurative lung disease. We
had no history of alcoholism, gallbladder disease
or abdominal pain. No clubbing of the fingers was
noted in the protocol. The x-rays, although sug-
gestive of bronchiectasis, surely aren’t diagnostic,
and we should have liked to see some broncho-
grams to substantiate clean-cut bronchiectasis as
the cause of his respiratory trouble. Again, there
were no skin tests or complement fixation tests
done to suggest any chronic lung disease. We felt
that there was insufficient evidence to justify a
discussion of any of the other causes of steator-
rhea. There was no radioactive fat absorption,
and we felt that the pancreas, as indicated in the
protocol, was the primary site.

The only other disease in which sweat chlorides
are consistently elevated is untreated adrenal in-
sufficiency. We didn’t find any evidence for that.
Elevated levels have also been reported in bron-
chiectasis, but some of the work that is now be-
ing reported raises a question as to whether these
are really true bronchiectases, or whether they
may not be cases of fibrocystic disease with man-
ifestations primarily in the lung and minimal sub-
clinical pancreatic involvement.

On this basis, then, we feel that this man had

cystic fibrosis of the pancreas, with a terminal
Pseudomonas pneumonia.

Dr. Paul M. Seebohm, Internal Medicine: Under
discussion today is a man who presented with
acute infection manifested by chills, a fever of
102°F. and leukocytosis. He gave a history of
having had recurrent infections in the form of
pneumonia once a year. This would suggest some
predisposing condition within the lung that might
account for recurrent infection, rather than a per-
sistent chronic infection.

The indications of pulmonary involvement with
infection were cough, purulent sputum, x-ray ev-
idence of a pneumonic-like infiltrate, rales, a his-
tory of sinusitis, and x-ray evidence of sinusitis.
Thus the respiratory tract certainly seemed to be
the site of the infection. Besides having had re-
current and acute pulmonary infections, he had
evidences of pulmonary dysfunction. The pulmo-
nary function tests showed a decreased vital capac-
ity, an increased residual volume, uneven dis-
tribution, decreased maximum breathing capacity
and decreased expiratory flow rate. These findings
are very suggestive of the changes usually seen
with pulmonary emphysema.

On one determination, with the patient breath-
ing room air, the oxygen saturation was 76 per
cent. However, the PC02 was within normal range
— 42 mm. Hg. At this time, I’d like to ask what the
oxygen saturation was when the patient was
breathing 100 per cent oxygen.

Dr. Bedell: The oxygen saturation was 100 per
cent + 0.05 vol. per cent.

Dr. Seebohm: That would then be consistent
with the changes we see with emphysema which
are diffuse throughout the lung and represent an
interference with ventilation. He did not have the
most serious complication of emphysema, name-
ly carbon dioxide retention.

I was interested in knowing the oxygen satura-
tion with the patient breathing 100 per cent oxy-
gen because with chronic lung infection and bron-
chiectasis it is not uncommon for parts of the lung
to be no longer air-bearing and possibly to serve
as vascular shunts, and one may have more
marked oxygen unsaturation without COo reten-
tion on the basis of a true vascular shunt through
a diseased portion of the lung. Apparently this
mechanism was not present in this patient, how-
ever.

At this juncture, I suppose one should consider
all the usual causes for chronic lung disease. In
emphysema with chronic bronchitis and recurrent
pneumonia, we certainly see this picture. Our pa-
tient was a little young to have had primary
emphysema for 38 years. Patients with bronchial
asthma have recurrent bronchitis, sinusitis and in-
fection. There was no evidence that this man ever
had had asthma, so we must eliminate it. The elec-
trocardiogram suggested that he had had a myo-
cardial infarct at some time in the past, and this

Vol. LII, No. 6

Journal of Iowa Medical Society

355

would make one suspicious that he might have
congestive failure. I think the absence of cardiac
enlargement and peripheral edema would con-
stitute evidence to the contrary, and certainly con-
gestive failure could not account for the lifetime
history, especially when there was no evidence of
valvular or congenital heart disease.

So we are left with a condition such as bron-
chiectasis with recurrent pneumonia or some
other predisposing condition within the lung.
Chronic recurring infections could have led to the
secondary emphysema and the resulting changes
in pulmonary function. It was noted that the
sputum was cultured and only Pseudomonas was
found. I’d like to ask Dr. Gillies a specific ques-
tion: What are the evidences of bronchiectasis
as reported here in the protocol?

Dr. Carl L. Gillies, Radiology : I think the diag-
nosis of bronchiectasis was probably made from
fright plus a little knowledge of the history. There
was diffuse fibrosis visible in both lungs, on chest
x-ray, and it didn’t change during the period of
observation. There was some diffuse pneumonitis,
but there was no atelectasis such as sometimes ac-
companies long-standing bronchiectasis. We do not
have a lung mapping to prove or disprove it. I
think we were influenced by the patient’s history
as much as by the x-rays.

Dr. Seebohm: The man also had some kind of a
gastrointestinal problem. He had bowel frequency
all of his life. We find in the protocol that there
was an absence of trypsin, and evidence of poor
absorption in the form of a low carotene level. He
also had a low cholesterol which I thought might
be evidence of poor absorption. The only way I
could fit it into the picture was to suggest that it
was low because the patient was not absorbing it.
Someone else may have a better explanation.

Mr. Cole and his colleagues were disturbed,
though I am not, by the fact that the patient is
supposed to have had a myocardial infarction at
38 years of age and when his cholesterol was less
than 100. Such an occurrence seems to strike at
the roots of some of our modern concepts.

Now the next question is whether there was
or was not some hepatic involvement, and I con-
cur with Mr. Cole and his group that we don’t
have any direct evidence of hepatic disease. Bil-
irubin, bromsulphalein and alkaline phosphatase
were all normal. The protein tests, however, were
abnormal. The albumin was down, suggesting gen-
eral malnutrition. A cephalin flocculation was ab-
normal, suggesting some aberration of the globulin,
and there was a slight increase in the globulin.
The zinc flocculation was also positive. These all
suggest abnormalities of the proteins. Whether
these were the result of a systemic disorder or
a liver involvement, I am unable to say. In the
course of reading papers on the disease that it
seems probable we are dealing with today, I got
the impression that the liver is occasionally ab-

normal at autopsy in such cases. So whether the
changes in the blood proteins were secondary to
malnutrition or to liver disease, I am unable to
say.

Now for the extraneous tests. The sweat chlo-
ride was elevated, and it has been pointed out that
it is elevated under only two conditions. One is
hypoadrenalism, and the other is cystic fibrosis of
the pancreas. The possibility of primary hypo-
adrenalism is not very good here because of the
duration of the chronic illness. One could contend,
I suppose, that the patient had a chonic lung prob-
lem and was treated with steroids, and then that
the medication was stopped before he came to
the hospital and was given a sweat test. I doubt
that such a series of events occurred, but it could
have been a reason for a false positive, and one
certainly should keep it in mind when doing sweat
chlorides on all patients with chronic cough and
chronic lung problems in an effort to find patients
with cystic fibrosis.

The possibility that multiple diseases might
have caused the patient’s pulmonary and gastro-
intestinal disorders I think has to be considered,
but not very seriously. My final impression was
much the same as that of Mr. Cole and his group.
The patient was an adult, but we are seeing this
disorder in adults now. He had had pneumonia
every year of his life, so I suspect that for at
least the last 20 years he had been treated with
some antibiotic, thus living longer than was pos-
sible for patients with this illness before the ad-
vent of the antibiotic era.

In conclusion, I think that we are dealing with
a man with cystic fibrosis of the pancreas and
secondary lung involvement. The only thing miss-
ing is the hemolytic Staphylococcus aureus in the
sputum which is usually found in this disorder.
Its absence may have been a consequence of
energetic antibiotic therapy just prior to the col-
lection of the sputum specimen.

The patient’s final episode, I thought, was due
to progression of the pneumonia and an acute
gastric dilatation. From the information in the
protocol, this was most likely, but I see now that
we have a film of the abdomen. Dr. Gillies, would
you interpret the x-rays?

Dr. Gillies: This is a film of the abdomen. It
does not show distention of the stomach, but the
small and large bowels are distended, giving the
appearance of an ileus rather than of an obstruc-
tion.

Dr. Seebohm: I have some difficulty in account-
ing for this as anything other than possibly a
peritonitis, which may have been either blood-
borne or due to a local perforation of the bowel.

Dr. Robert Soper, Surgery: Was the patient
ever treated with pancreatic extract, Decholin,
Viokase, or similar drugs?

Dr. Bedell: I don’t believe that he was. Dr. Clif-

blood pressure approaches normal
more readily, more safely.... simply

(hydroflumethiazide, reserpine, protoveratrine A-antihypertensive formulation)

Early, efficient reduction of blood pressure. Only Salutensin combines
the advantages of protoveratrine A (“the most physiologic, hemody-
namic reversal of hypertension”1) with the basic benefits of thiazide-
rauwolfia therapy. The potentiating/additive effects of these agents2"6
provide increased antihypertensive control at dosage levels which
reduce the incidence and severity of unwanted effects.

Each Salutensin tablet contains: 50 mg. Saluron® (hydroflumethiazide), 0.125 mg. reserpine, and
0.2 mg, protoveratrine A. See Official Package Circular for complete information on dosage, side
effects and precautions.

Supplied: Bottles of 60 scored tablets.

References: 1. Fries, E. D.: In Hypertension, ed. by J. H. Moyer, Saunders, Phila., 1959 p. 123.
2. Fries, E. D.: South M. J. 51:1281 (Oct.) 1958. 3. Finnerty, F. A. and Buchholz, J. H.: GP 17:95
(Feb.) 1958. 4. Gill, R. J., et al.: Am. Pract. & Digest Treat. 11:1007 (Dec.) 1960. 5. Brest, A. N.
and Moyer, J. H.: J. South Carolina M. A. 56:171 (May) 1960. 6. Wilkins R. W.: Postgrad. Med.
26:59 (July) 1959. 7. Gifford, R. W., Jr.: Read at the Hahnemann Symp. on Hypertension, Phila.
Dec. 8 to 13, 1958. 8. Fries, E. D., eTal.: J. A. M. A. 166:137 (Jan. 11) 1958. 9. Ford, R. V. and
Nickel!, J.: Ant. Med. &. Clin. Ther. 6:461, 1959.

all the antihypertensive benefits of thiazide-
rauwolfia therapy plus the specific,
physiologic vasodilation of protoveratrine A

11 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS BY SERIAL ADDITION OF
THE INGREDIENTS IN SALUTENSIN IN A TEST CASE

(Adapted from Spiotta, E. J.: Report to Department of Clinical Investigation, Bristol Laboratories)

SALUTENSIN

Hg.

190

180

170

160

150

140

130

120

110

100

thiazide

protoveratrine A

(thiazide
protoveratrine A
reserpine)

JAN. FEB. MARCH

12 19 27 3 10 17 24 2 9 17 23 30

3V2 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS USING SALUTENSIN FROM
THE START OF THERAPY IN A “DOUBLE BLIND” CROSSOVER STUDY

Mean Blood Pressures-Systolic (S) and Diastolic (D)

mm
Hg.

190
180
170
160
150
140
130
120
110
100
90
80
70
60
50

BRISTOL LABORATORIES/Div.of Bristol-Myers Co., Syracuse, N.Y.

Placebo Followed by Salutensin
(22 patients)

Salutensin Followed by Placebo
(23 patients)

Placebo Salutensin

Before After Before After

Salutensin Placebo

Before After Before After

358

Journal of Iowa Medical Society

June, 1962

ton, do you remember whether he had bile salt,
pancreatic extract or similar drugs?

Dr. James Clifton, Internal Medicine: No, he
had never been treated for this pancreatic dis-
order.

Student: We can assume, then, that this diagno-
sis had never been made before he came here.

Dr. Bedell: As you will remember from the pro-
tocol, he had been admitted to the Oakdale Hos-
pital because he had a chronic lung infection and
because there was considerable concern over the
possibility of tuberculosis. He was worked up at
Oakdale, and the clinical diagnosis of cystic fibro-
sis was made there. He was transferred to our
hospital with the clinical diagnosis of cystic fibro-
sis of the pancreas with chronic lung infection,
and here he was treated with many antibiotics
to try to clear up his lung infection, but he did
not respond.

Dr. Emory Warner, Pathology: I think I might
start by pointing out one or two things that the
patient did not have. He did not have athero-
sclerosis of the coronary arteries, and he did not
have a myocardial infarct. At the time of autopsy,
abdominal distention was rather inconspicuous.
The last film was taken four days before his
death, and perhaps the gastric suction was quite
effective. There was mild ascites — 350 ml. — and
there was moderate distention of the small bowel.

Now, to come to what the patient did have. He
did have cystic fibrosis of the pancreas, if you use
the term as the name of a disease entity rather
than as a means of describing the patient’s pan-
creas. For practical purposes, there was no exo-
crine pancreas. However, he did not have a fibrot-
ic pancreas, nor did he have a cystic pancreas.
The pancreas, in yester-years, would have been
said to exhibit “extreme adiposity.” The organ
was of essentially normal size, shape and location,
but on gross inspection was almost entirely made
up of adipose tissue. Normal islets were distrib-
uted throughout the fatty mass. The bulk of the
structure was made up of fibroadipose tissue, with
emphasis on the adipose tissue. Scarring was very
inconspicuous. There was practically no cystic
change.

The other site of significant disease was in the
patient’s lungs. He did not have appreciable bron-
chiectasis. There was emphysema of moderate de-
gree, with patchy atelectasis. Pneumonia was
present throughout all lobes as a patchy, multi-
nodular lesion. Although the individual nodules
were not large, they were numerous and resulted
in extensive disease. There was a very active pur-
ulent bronchitis. In addition, there was consider-
able chronic bronchitis with chronic inflammatory
infiltrate in the bronchial walls. Again I would
like to stress that in spite of the extensive pul-

Figure I. Gross photo of pancreas showing essentially normal size and shape, and absence of gross fibrocystic change.

Vol. LII, No. 6

Journal of Iowa Medical Society

359

monary disease, with chronic as well as acute
bronchitis, there was very little bronchial dilata-
tion. Patchy fibrosis with an old chronic pneu-
monitis was present, but this again was not exten-
sive.

The pancreas was essentially normal in size and
shape. It weighed 80 Gm., as compared with a
normal average of perhaps 90-100 Gm.

His liver was small, weighing only 1,100 Gm.,
but the patient was not a large man. Microscop-
ically, the liver showed a very mild fatty meta-
morphosis and slight pei’iportal fibrosis. He cer-
tainly did not have a cirrhotic liver in the ordi-
nary sense, nor was there evidence of mucovis-
cidosis involving the bile ducts.

The microscopic slides of pancreas were all sim-
ilar. They showed adipose tissue in which there
were numerous pancreatic islets. The adipose tis-
sue was divided up by septa of fibrous connective
tissue without appreciable inflammatory reaction.
The islets were perhaps a little more numerous
than normal, but when one considers that the pan-
creatic parenchyma of exocrine type was almost
absent, it seems likely that the apparent increase
in the number of islets was not real. There were
a few foci microscopically in which residual de-
generating pancreatic acinar tissue could be found.
In these, there was some dilatation of a few of the

Figure 2. Typical section of pancreas showing numerous
islets scattered in the fibroadipose tissue which replaced
the pancreatic parenchyma.

very small ducts. An occasional larger duct had
some mucoid material which appeared rather in-
spissated and which filled the lumen. This, how-
ever, was a very inconspicuous finding. The main
pancreatic duct showed dilatation of the small
ducts and mucous glands in its wall, but there was
no true cyst formation.

There were multiple small foci of squamous
metaplasia present in the bronchi. With the faulty
absorption, vitamin-A deficiency might have been
expected to occur in the patient. This, as well as
chronic bronchitis, would have tended to cause
squamous metaplasia.

What have we to support the diagnosis of cystic
fibrosis in this case? Why might not this be a case
in which the pancreas was destroyed by some
virus infection, for example, with resultant pan-
creatic insufficiency leading to nutritional de-
ficiency— malabsorption, if you will — and the rest
of the story secondary to pancreatic destruction?

In favor of the diagnosis of cystic fibrosis, we
have the positive sweat test, which is generally
considered to be diagnostic. Also, there was some
dilatation of mucous glands along the pancreatic
duct, and some similar dilatation was present in
Brunner’s glands in the duodenum. The chronic
lung disease, although rather non-specific, certain-
ly fits with the diagnosis of cystic fibrosis. The

Figure 3. High-power view of one of the few areas in which
remnants of exocrine pancreatic tissue were present. Note
dilated small duct with mucoid content.

360

Journal of Iowa Medical Society

June, 1962

absence of bronchiectasis is in accord with cystic
fibrosis, rather than against that diagnosis. Al-
though neither cyst formation nor fibrosis was
present to a significant degree in the pancreas,
the pancreatic findings were not against the diag-
nosis of cystic fibrosis.

It is worth stressing that as cases of cystic fibro-
sis have been followed up into the teen-age period
and into young adulthood, it has become evident
that increasing adiposity of the pancreas is likely
to occur. It is in the infant and the younger child
that we see the classic changes of extensive fibro-
plasia and dilatation of the ducts. As time goes on,
there is progressive ingrowth of adipose tissue,
with replacement of the pancreatic exocrine tis-
sue. Also, fibroplasia ceases, and the excess con-
nective tissue is gradually replaced by adipose
tissue. In the later stages, inflammatory reaction
is minimal.

Thus, the pancreatic findings in this case — ex-
tensive adiposity, practically no inflammation
and a virtual absence of exocrine tissue — do not
rule out the diagnosis of cystic fibrosis. In fact, the
findings are quite in accord with what one might
expect in a patient who had survived to the age
that this man had reached.

Mr. Steven Bauserman, junior ward clerk: Are
we assume that this is an abnormal form of this
disease having a hidden progression that allows
people to live to the age of 40 years, rather than
making them die in their teens, as one commonly
expects?

Dr. Warner: I think we should expect to en-
counter relatively mild cases of most diseases.
This is true even of such diseases as hemophilia.
Though at first glance it would seem that the de-
fect in hemophilia should be all or none, actual-
ly we find all degrees from very mild, unsuspect-
ed and undetected cases to the full-blown classic
disease. It seems reasonable to expect a compar-
able range among the cases of fibrocystic disease.

To answer your question more specifically, I
should say yes, I think this patient’s case of fibro-
cystic disease was sufficiently mild to permit his
survival into the antibiotic era, and then to allow
his being carried for another decade or two by
antibiotics.

Mr. Bauserman: So you think that in the future
more cases will have been spared for considerable
periods by antibiotics.

Dr. Warner: I think more patients with fibro-
cystic disease will reach adult life in the future.
I think also that there have been more such pa-
tients in the past than we have recognized.

Dr. Seebohm: I’d like you to expound a little
further on the mechanism by which the lung part
of this picture develops. You mentioned vitamin- A
deficiency. Did you see any glandular changes in
the lung?

Dr. Warner: In my remark about vitamin- A de-
ficiency, I was referring to the squamous meta-

plasia in the bronchi. With the malabsorption and
the low blood carotene, we might have anticipated
that he would have a vitamin-A deficiency. This is
known to predispose to squamous metaplasia of
bronchial epithelium. It was in that connection
that I referred to vitamin-A deficiency.

In regard to the pathogenesis of the lung lesions,
I think we don’t have a very clear concept at the
present time. One would have difficulty in main-
taining that the complete explanation is mucovis-
cidosis, with sticky mucus that cannot be coughed
up, thereby causing mechanical obstruction, a re-
sulting infection and the subsequent chain of
events. Bronchiectasis, typically, is inconspicuous.
Were obstruction the major factor, we would ex-
pect much more bronchiectasis. The mucus is chem-
ically— or at least histochemically — normal, ac-
cording to some workers. Its stickiness is not be-
yond the stickiness we see with chronic bronchitis
from other causes. Viscosity of mucus, which has
been much stressed, may merely reflect water
content rather than an unusual chemical struc-
ture. There is an extreme susceptibility to pul-
monary infection in these patients, and this suscep-
tibility may be the major factor rather than sim-
ple mechanical obstruction. Certainly it is dif-
ficult to see how abnormal mucus, as the basic
genetic defect, can explain the abnormal salt con-
tent of the sweat.

Mr. Cole: What did the patient’s adrenals look
like?

Dr. Warner: Everything else was essentially nor-
mal. He had some atrophy of the testes, with asper-
mia.

Student: How about the salivary glands? Were
they looked at?

Dr. Warner: The submaxillary gland was entire-
ly normal. The sublingual gland was not taken, nor
was the parotid gland, although a number of pieces
of tissue from the parotid region were removed for
section. Whether the parotid gland was atrophic
or not, it is impossible to say. In Dr. Anderson’s
last article, salivary-gland changes were described
in some detail. Apparently both parotid and sub-
maxillary glands usually are normal in classic
cases of this disease. The sublingual, however, is
likely to show the disease. Unfortunately, the sub-
lingual was not examined in this case.

Dr. Seebohm: I’d like to ask Dr. Clifton whether
adults with the malabsorption syndromes have a
high incidence of lung infection, and also whether
it is usually found that their carotene blood val-
ues are low.

Dr. Clifton: Their carotene blood values are
usually low, and as a group they do not tend to
have chronic lung infections.

Student: Will someone comment on the low cho-
lesterol value?

Dr. Clifton: Patients with long-standing mal-
absorption usually have low serum cholesterol.

Vol. LII, No. 6

Journal of Iowa Medical Society

361

Student: Are there any studies to show that the
pancreatic enzymes affect the lung picture in any
way?

Dr. Bedell: The administration of pancreatic en-
zymes has no particular effect on the lung. In
other words, pancreatic enzymes usually help the
patient symptomatically, but changes in absorp-
tion of digestive products do not alter the course
of the disease as far as the lung is concerned.

Dr. Robert D. Gauchat, Pediatrics: I should like
to comment on the nature of mucoid secretions of
patients with cystic fibrosis. In the published trans-
actions of the International Research Conference
on Cystic Fibrosis, held in Washington, D. C., in
1959, 3 considerable information concerning the
chemical and physical properties of these mucoid
secretions is presented by leading investigators of
this disease. Abnormalities in mucous secretions
are most strikingly demonstrable in the pancreatic
secretions obtained both from the duodenum and
from the bronchi. Shwachman was the first to
point out that duodenal juice is abnormally vis-
cous in these patients, and measurement of this
increased viscosity of duodenal fluid is employed
at some medical centers, along with measurement
of tryptic activity of the duodenal fluid, as a
means of establishing the diagnosis of cystic fibro-
sis.

In 1957, Dische and di Sant’Agnese further
demonstrated that there is a mucopolysaccharide
in the duodenal fluid of the fibrocystic patient,
which becomes denatured and loses its solubility
in water when it is precipitated and which is not
present in normal control subjects. Interestingly
enough, this abnormal mucopolysaccharide is pres-
ent in the duodenal fluids of most patients with
cystic fibrosis, even though pancreatic tryptic ac-
tivity may not yet have been lost by progressive
pancreatic fibrosis. More recently, Dische has
found abnormalities in the sialic acid and fucose
content of this peculiar mucopolysaccharide.

As regards the pulmonary secretions, they are
more viscid than normal, and they also appear to
differ from the secretions produced by patients
with bronchiectasis. The bronchial secretions of
the fibrocystic patients contain more nucleopro-
tein (DNA) than do either normal or bronchiec-
tatic secretions, and are very resistant to break-
down by various proteolytic enzymes. The only
enzyme which produces a marked decrease in the
viscosity of fibrocystic bronchial mucus is pan-
creatic dornase, and this fact suggests that the
nucleoproteins constitute an important contribu-
tion to the overall viscosity of these secretions.

Several years ago, Dr. Warner, I attended all
postmortem examinations of fibrocystic patients to
collect bronchial contents so that Dr. Charles D.
May and I might study them. We hoped to obtain
enough bronchial mucus from those patients to
permit a search for ways of reducing the viscosity

of the mucus by enzymatic means, so that patients
could cough out their secretions more easily.
Using a 50 ml. syringe — the largest needle I could
find — and using as much suction as I could exert
with that apparatus, I was unable to withdraw
more than a very small amount of that bronchial
mucus because of its extreme stickiness and its
tenacious attachment to the bronchial lining.

Dr. Seebohm has commented that the presence
of Pseudomonas organisms in this man’s bronchial
tree is an unusual finding. In recent years, with
the use of more and more potent antibiotics to
combat the characteristic staphylococcal infection
seen in patients with cystic fibrosis, we have come
to recognize Pseudomonas organisms as second
and even more serious invaders of the lungs
of these patients. Pseudomonas organisms adapt
quickly to most chemotherapeutic agents, and are
widely distributed both in external and internal
human environments. They are therefore ideally
equipped to settle down and grow when the more
potent Staphylococci have been inhibited by anti-
biotic therapy. The characteristic stickiness or vis-
cosity of its culture no doubt enhances its ability
of the Pseudomonas to survive competitively in
these sticky secretions.

Once the Pseudomonas has invaded and become
established in the bronchi of a fibrocystic patient,
it is extremely difficult to remove it by any form
of chemotherapy, and the prognosis for the patient
is grave. Nebulized antibiotics and postural drain-
age have proved ineffective as methods of combat-
ting the Pseudomonas. At the present time, we are
approaching this problem by preparing autoge-
nous vaccines using the Pseudomonas cultured
from the patient’s sputum, and we are employ-
ing this vaccine in the old-fashioned, traditional
way in an effort to stimulate antibody production
against the Pseudomonas. In two cases, short-
range improvement in pulmonary function has
been observed, but more time must elapse before
we can assess the value of this approach. In two
other cases, I believe that we have eliminated
the Pseudomonas by stopping all antibiotic ther-
apy in order to allow the presumably more vir-
ulent Staphylococci to overgrow and eliminate the
Pseudomonas organisms. This technic is obviously
fraught with hazards, and needs to be done under
close supervision within the hospital. We are al-
ways reluctant to hospitalize children with cystic
fibrosis unless it becomes absolutely necessary,
because of the possibility of their exposure to hos-
pital strains of Staphylococci.

In my opinion, the case presented today is im-
portant because it reports one of the longest-sur-
viving patients with cystic fibrosis for whom com-
plete pathologic findings are known. Shwachman4
has reported that only three patients from a series
of 266 seen in Boston have survived beyond the
age of 20 years, and that his oldest surviving fibro-

362

Journal of Iowa Medical Society

June, 1962

cystic patient is 35 years old. Among the 550 pa-
tients seen by Andersen and di Sant’Agnese in
New York,5 only 20 per cent survived beyond the
age of 10 years, the oldest patient being 24 years
of age.

It is interesting to speculate whether one factor
contributing to our patient’s long productive life
may have been that he escaped from the contin-
uous antibiotic therapy now employed traditional-
ly in the management of cystic fibrosis!

For those who wish to extend their knowledge
of cystic fibrosis as it presents itself in adolescents
and young adults, I should recommend the edito-
rial by di Sant’Agnese and Andersen published in
the annals of internal medicine for May, 1959, 6
in which they describe their experience with
fibrocystic children beyond the age of 10 years
and into adulthood. There is no doubt that cystic
fibrosis can no longer be thought of as a purely
pediatric disease.

STUDENTS' DIAGNOSES

Cystic fibrosis of the pancreas

Pseudomonas pneumonia

DR. SEEBOHM'S DIAGNOSES

Cystic fibrosis of the pancreas

Acute gastric dilatation

Pseudomonas pneumonia

Coming

IOWA

June 18-21 Spring Postgraduate Conference (Iowa Chap-
ter of the American Academy of General
Practice). The New Inn, Lake Okoboji

CONTINENTAL U. S.

June

1-2

Medical Emergencies. U.C.L.A., Los Angeles

June

1-3

Back Pain. University of California, San Fran-
cisco

June

1-29

Internal Medicine. Harvard Medical School,
Boston

June

Lederle Symposium. Davenport Hotel, Spo-
kane, Washington

June

4-8

Surgery of Colon and Rectum. Cook County
Graduate School of Medicine, Chicago

June

4-8

Psychiatry for the Internist (American Col-
lege of Physicians). The Psychiatric Institute,
University of Maryland School of Medicine,
Baltimore

June

4-8

Hematology. Cook County Graduate School of
Medicine, Chicago

June

4-9

Histochemistry. University of Kansas Medical
Center, Kansas City, Kansas

June

4-9

Basic Science and Its Relation to Internal
Medicine. Harvard Medical School, Boston

June

4-15

Surgical Technic. Cook County Graduate
School of Medicine, Chicago

June

4-22

General Surgery. Harvard Medical School,
Boston

CLINICAL DIAGNOSES

Cystic fibrosis of the pancreas
Pseudomonas pneumonia

ANATOMICAL DIAGNOSES

Fibrocystic disease of the pancreas
Bronchopneumonia, bilateral, severe
Pleural effusion, bilateral
Ascites, 350 ml.

Emaciation

Ecchymoses, hips and right leg
Splenomegaly, 320 Gm.

Dilation of right seminal vesicle.

REFERENCES

1. Anderson, C. M., and Freeman, M. : Simple method of
sweat collection with analysis of electrolytes in patients with
fibrocystic disease of pancreas, and their families. Med. J.
Australia, 1:419-422, (Mar. 29) 1958.

2. Marks, L., and Anderson, M.: Fibrocystic disease of pan-
creas in man aged 46. Lancet, 1:365-367, (Feb. 13) 1960.

3. McIntosh, R., ed.: Research on Cystic Fibrosis. In:
Transactions of the International Research Conference on
Cystic Fibrosis, Washington, D. C., January 7-9, 1959. Balti-
more, The French-Bray Printing Co., 1960.

4. Kulczycki, L. L., Mueller, H., and Shwachman, H.:
Respiratory allergy in patients with cystic fibrosis. J.A.M.A.,
175:358-364, (Feb. 4) 1961.

5. di Sant’Agnese, P. A., and Vidaurreta, A. M.: Cystic
fibrosis of pancreas. J.A.M.A., 172:2065-2072, (Apr. 30) 1960.

6. di Sant’Agnese, P. A., and Andersen, D. H.: Cystic
fibrosis of pancreas in young adults (Editorial). Ann. Int.
Med., 50:1321-1330. (May) 1959.

Meetings

June

4-22

Forty-seventh Annual Postgraduate Session of
the Trudeau School of Tuberculosis and Other
Pulmonary Diseases. Saranac Lake, New York

June

7-9

Corneal Lens: Theory and Application. Uni-
versity of California, San Francisco

June

10-16

General Surgery. University of Nebraska Col-
lege of Medicine, Omaha

June

New Hope for the Mentally Retarded Child.

University of Kansas School of Medicine,
Kansas City, Kansas

June

11-16

Histochemistry. University of Kansas Medical
Center, Kansas City, Kansas

June

11-22

Fractures and Traumatic Surgery. Cook Coun-
ty Graduate School of Medicine, Chicago

June

11-22

Neuromuscular Diseases. Cook County Grad-
uate School of Medicine, Chicago

June

14-17

American Electroenceplialographic Society.

Claridge Hotel, Atlantic City

June

17-23

Obstetrics and Gynecology. University of Ne-
braska College of Medicine, Omaha

June

18-20

Gallbladder Surgery. Cook County Graduate
School of Medicine, Chicago

June

18-20

American Geriatrics Society. Palmer House,
Chicago

June

18-20

American Neurological Association. Claridge
Hotel, Atlantic City

June

18-22

Advanced Electrocardiography. Cook County
Graduate School of Medicine, Chicago

Vol. LII, No. 6

Journal of Iowa Medical Society

363

June 18-22

June 21-22

June 21-23

June 21-23
June 21-24

June 21-25

June 22-23
June 22-24
June 23

June 23

June 23
June 23

June 23-24
June 24
June 24
June 24-28
June 25-27
June 25-29
June 25-July 6

June 27-30
June 28-30

June 30-July 1

July 1-4
July 3-8
July 5-6
July 9-12

July 9-13
July 13-14

Canadian Medical Association. Royal Alexan-
dria Hotel, Winnipeg

July 16-27 Obstetrics, General and Surgical. Cook Coun-
ty Graduate School of Medicine, Chicago

Annual Educational Conference, National As-
sociation of Sanitarians. Cincinnati

July 19-21 Dermatology for General Practitioners. Uni-
versity of Colorado Medical Center, Denver

American Rheumatism Association. Edgewater
Beach Hotel, Chicago

Surgery of Hernia. Cook County Graduate
School of Medicine, Chicago

July 23-27 Cardiopulmonary Problems in Children (Amer-
ican College of Chest Physicians). Edgewater
Beach Hotel, Chicago

July 23- Surgical Technic. Cook County Graduate

Aug. 3 School of Medicine, Chicago

Endocrine Society. Palmer House, Chicago

American Therapeutic Society. McCormick
Place, Chicago

Twenty-eighth Annual Meeting of the Amer-
ican College of Chest Physicians. Morrison
Hotel, Chicago

Urology. Stanford University School of Med-
icine, Palo Alto, California

International College of Angiology. Conrad
Hilton Hotel, Chicago

Community Preparedness for Emergencies —
Tenth Annual National Conference on Disas-
ter Medical Care (AMA). Palmer House,
Chicago

International Cardiovascular Society, North
American Chapter. Conrad Hilton Hotel,
Chicago

American Academy of Tuberculosis Phy-
sicians. Palmer House, Chicago

July 30-
Aug. 3

Audiology Workshop (University of Colorado
Medical Center). Estes Park, Colorado

ABROAD

June 16-21

July 1-4

July 1-7

July 8-12

International Symposium on Enzymic Activity
in the Central Nervous System, Goteborg,
Sweden. Write: Dr. A. Lowenthal, Institut
Bunge, 59 rue Philippe Williot, Berchem-
Antwerp, Belgium

International Conference on Oral Surgery.
Royal College, London. Write: D. C. Trexler,
Executive Secretary, American Society of Oral
Surgeons, 840 North Lake Shore Drive, Chica-
go 11

From Disability to Work (The British Coun-
cil for Rehabilitation of the Disabled), Euro-
pean International Study Course and Confer-
ence. Cambridge University, London

International Congress of Psychosomatic Med-
icine and Childbirth. Paris. Contact: Dr. L.
Chertok, 22 rue Legendre, Paris 17, France

Annual Meeting of the American Association
for the Study of Headache. Palmer House,
Chicago

July 28-
Aug. 3

Pan American and South American Pediatric
Congress. Quito, Ecuador. Write: Dr. Jorge
Vallarino, P.O. Box 2269, Quito, Ecuador

American Diabetes Association, Inc. Conrad
Hilton Hotel, Chicago

Society for Vascular Surgery. Conrad Hilton
Hotel, Chicago

Society for Surgery of the Alimentary Tract.
Sheraton-Chicago, Chicago

llltli Annual Meeting of the American Med-
ical Association. Chicago

July 30-
Aug. 13

Aug. 8-15

International Fertility Association, 4th World

Congress, Hotel Copocabana, Rio de Janeiro.
Write: Dr. Maxwell Roland, Secretary, 109-23
71st Road, Forest Hills 75, New York

Obstetrics and Gynecology. University of
Colorado Medical Center, Denver

Vaginal Approach to Pelvic Surgery. Cook
County Graduate School of Medicine, Chicago

Electrical Technics in Biology and Medicine
(Case Institute of Technology). University
Circle, Cleveland

Ninth Annual Meeting, Society of Nuclear
Medicine. Baker Hotel, Dallas

International Conference on Opportunistic
(Secondary) Fungus Infections. Durham, North
Carolina

Workshop in Clinical Hypnosis (American
Society of Clinical Hypnosis — Education and
Research Foundation). Sheraton-Chicago Ho-
tel, Chicago

Sept. 3-7

Sept. 5-8

Sept.

First International Conference on Water Pol-
lution Research. London. Write: Mr. W. Wes-
ley Eckenfelder, Jr., Manhattan College En-
vironmental Engineering Research Laboratory,
514 Sylvan Avenue, Englewood Cliffs, New
Jersey

International Congress of Internal Medicine,

Munich, Germany. Write: Professor Dr. E.
Wollheim (President of Congress), Luitpold-
krankenhaus, Wurzburg, Germany

International Congress of Infectious Pathol-
ogy, Bucharest, Rumania. Write: Professor S.
Nicolau, Via Parigi, 7-Bucharest

Third International Conference on Alcohol
and Road Traffic, London. Write: Mr. J. D. J.
Havard, Secretary, Committee on Manage-
ment, British Medical Association House, Tavi-
stock Square, London

International College of Surgeons’ New Eng-
land Regional Meeting. Mt. Washington Hotel,
Bretton Woods, N. H.

Seminar for General Practitioners (UCLA).

University Residential Conference Center,
Lake Arrowhead, California

Practical Applications in the Management and
Rehabilitation of Arthritis. University of Col-
orado Medical Center, Denver

Medical and Surgical Aspects of the Retina
(University of Colorado School of Medicine)
and Summer Convention of the Colorado
Ophthalmological Society. The Stanley Hotel,
Estes Park, Colorado

Symposium for General Practitioners on Tu-
berculosis and Other Pulmonary Diseases
(American Thoracic Society, Saranac Lake
Medical Society, New York State Academy
of General Practice, Canadian College of Gen-
eral Practice). Saranac Lake, New York

Rocky Mountain Cancer Conference. Brown
Palace Hotel, Denver

Oct.

Oct. 7-13
Oct. 22-28

Nov. 11-16
Dec.

Feb. 20-24,
1963

American Society of Plastic and Reconstruc-
tive Surgery, Hawaiian Village Hotel, Hono-
lulu. Write: T. Ray Broadhent, M.D., Sec-
retary, 508 East South Temple, Salt Lake City

World Congress of Cardiology, Medical Cen-
ter, Mexico City. Write: Dr. I. Costero, In-
stitute N. De Cardiologia, Avenida Cuauhte-
moc 300, Mexico 7, D. F.

International Medical World Conference on
Organizing Family Doctor Care. Victoria Halls,
Southampton Row, London. Write: The Editor,
The Medical World, 56 Russell Street, Lon-
don, W.C.I.

World Medical Association. Vigyan Bhawan
Building, New Delhi, India. Write: Dr. Harry
S. Gear, 10 Columbus Circle, New York 19

International Congress of Medical Women’s
International Association. Philippines. Write :
Dr. Rosita Rivera-Ramirez, Sta. Teresita Hos-
pital, 82 D. Tuazon, Quezon City, Philippines

Seventh International Congress on Diseases of
the Chest (American College of Chest Phy-
sicians). New Delhi, India

364

Journal of Iowa Medical Society

June, 1962

xr7

Care in the Use of Terms

The rapid increase in the use of chemotherapy
in treating disease has given rise to a large number
of unfortunate results. Numerous terms intended
to convey specific meanings are frequently used
incorrectly in designating adverse reactions. The
loose application of those terms has produced a
great deal of confusion.

In a general introduction to a symposium on
drug sensitization presented at a meeting of the
Royal Society of Medicine, Professor M. L. Rosen-
heim* elaborated recently upon a classification of
untoward effects of drugs suggested by F. A.
Brown in 1955. Though there is considerable over-
lap and though it isn’t always possible to classify
an individual drug reaction accurately, adherence
to the classification will eliminate much of the
confusion.

According to this British physician, the adverse
reactions can be put into one or another of the
following six categories:

1. Overdosage. Toxic effects from overdosage
are usually predictable as a result of animal ex-
perimentation and clinical trials. Overdosage may
be absolute in cases in which an excessive amount
has been given in error. An alteration in the meta-
bolic state or an impairment of normal destruction
or excretion, however, may lead to an excessive
effect from no more than a normal dose. In cases
of liver failure, a normal dose of morphine may
be dangerous. In hypokalemic states there is a
potentiation of digitalis. In renal failure, strepto-
mycin or hexamethonium has a prolonged effect.
The recommended doses of certain antibiotics in
the treatment of infection in premature infants
have proved excessive and in some instances have
proved fatal.

2. Intolerance. Drug intolerance is a lowered
threshold to the normal pharmacologic action of
the drug. There is considerable variation from
patient to patient in the response to drugs, and
though it has not been proved, it is possible that
there is a biochemical cause for the variation in
tolerance.

3. Side Effects. These are the therapeutically
undesirable but unavoidable effects of drugs. A
drug is selected for a specific pharmacologic action,
but dosage may have to be limited because of other

pharmacologic actions — not toxic effects, but other
inevitable results. The use of ganglion-blocking
agents is limited by the parasympathetic blockade
that occurs along with the sympathetic block. Cer-
tain drugs may interfere with normal metabolic
pathways. Anti-eleptic drugs may provoke a meg-
aloblastic anemia which is relieved by folic acid.

4. Secondary Effects. These are the indirect
consequences of primary drug action. The change
in the intestinal flora following tetracycline ther-
apy, with signs of either vitamin deficiency or
superinfection with other organisms, is a classic
example of a secondary effect. The Herxheimer
reaction due to released products of killed orga-
nisms falls into this category.

5. Idiosyncrasy. This is an inherent qualitative
abnormal reaction to a drug. The reaction occurs
when a drug is first given, and is not the result of
an acquired sensitivity. It is an abnormal response
and not just an exaggeration of a normal one. The
term idiosyncrasy is frequently misused as a syno-
nym for hypersensitivity , but an idiosyncrasy is
not an antigen-antibody response. A true idiosyn-
crasy, for example, is the development of hemolytic
anemia in some 10 per cent of American Negroes
when given the antimalarial drug primaquine. This
reaction is thought to reflect an inherent deficiency
of glucose-6-phosphate dehydrogenase in the red
blood cells. The hemolytic anemia which occurs
with sulfonamide and nitrofurantoin therapy is
attributable to idiosyncrasy. An inherited enzyme
defect may cause both an idiosyncrasy and an in-
tolerance.

6. Hypersensitivity. This is an untoward re-
action which has been conditioned by a previous
exposure to the drug, and it is essentially an
antigen-antibody reaction. It may be immediate or
delayed, and it occurs more frequently in patients
who suffer from allergic disorders. Acute anaphy-
laxis is the most serious hypersensitivity reaction.
Drug-induced thrombocytopenic purpura, some
forms of agranulocytosis and hemolytic anemia,
and many urticarial reactions are sensitivity re-
actions.

Confronted with the list of drugs associated with
blood dyscrasia that has been compiled by the
AMA Council on Drugs, one finds it difficult to
classify the untoward reactions accurately. The
precise mechanisms of many reactions have not
yet been elucidated. It does not contribute to clar-
ity or accuracy, however, for medical authors to
use the term drug idiosyncrasy as if it were the
common denominator for this whole group of un-
toward reactions.

Attend the

AMA ANNUAL MEETING
McCormick Place, Chicago
June 24-28

* Rosenheim, M. L.: Symposium on drug sensitization: gen-
eral introduction, proc. royal soc. med., 55:7-8, (Jan.) 1962.

Vol. LII, No. 6

Journal of Iowa Medical Society

365

Villain or Hero

Too much emphasis cannot be given to the fact
that each individual physician is a public relations
representative of the medical profession. The pub-
lic image is determined by the integrity, the fair-
ness, the kindness, the compassion, the competency
of each physician in his relationship with each in-
dividual patient. It is generally recognized that
there has been an unfortunate deterioration in the
attitude of the layman toward our profession, and
in particular toward organized medicine. The re-
gaining of the layman’s former wholesome regard,
respect and confidence is the obligation of every
physician.

Some of the most critical of our fellow citizens
show gratitude toward and confidence in their own
particular doctors, but there are others whose
memories appear to be unconscionably short.
Somehow their attitude brings to mind “Tommy,”
a poem from the pen of Rudyard Kipling:

I went into a public- ouse to get a pint of beer,

The publican ’e up an’ sez, “We serve no red-coats
here.”

The girls be’ind the bar they laughed an’ giggled
fit to die,

I outs into the street again an’ to myself sez I:

O it’s “Tommy this, an’ Tommy that, an’ Tommy,
go away” ;

But it’s “Thank you, Mister Atkins,” when the
band begins to play —

The band begins to play, my boys, the band begins
to play,

0 it’s “Thank you, Mister Atkins,” when the band
begins to play.

1 went into a theater as sober as coidd be,

They gave a drunk civilian room, but ’adn’t none
for me;

They sent me to the gallery or round the music-
’alls,

But when it comes to fightin’ , Lord! they’ll shove
me in the stalls!

For it’s Tommy this, an’ Tommy that, an’ “Tommy,
wait outside”;

But it’s “Special train for Atkins” when the
trooper’s on the tide —

The troopship’s cn the tide, my boys, the troop-
ship’s on the tide,

O it’s “Special train for Atkins” when the trooper’s
on the tide.

Yes, makin’ mock o’ uniforms that guard you while
you sleep

Is cheaper than them uniforms, an’ they’re starva-
tion cheap;

An’ hustlin’ drunken soldiers when they’re goin’
large a bit

Is five times better business than paradin’ in fidl
kit.

Then it’s Tommy this, an’ Tommy that, an’ “Tom-
my, ’ ow’s yer soul?”

But it’s “Thin red line of ’eroes” when the drums
begin to roll —

The drums begin to roll, my boys, the drums begin
to roll,

O it’s “Thin red line of ’eroes” when the drums
begin to roll.

We aren’t no thin red ’eroes, nor we aren’t no
blackguards too,

But single men in barracks, most remarkable like
you;

An’ if sometimes our ccnduck isn’t all your fancy
paints,

Why single men in barracks don’t grow into plaster
saints;

While it’s “Tommy this, an’ Tommy that, an’
Tommy, fall be’ind,”

But it’s “Please to walk in front, sir,” when there’s
trouble in the wind —

There’s trouble in the wind, my boys, there’s
trouble in the wind,

O it’s “Please to walk in front, sir,” when there’s
trouble in the wind.

You talk o’ better food for us, an’ schools, an’
fires, an’ all:

We’ll wait for extry rations if you treat us rational.

Don’t mess about the cook-room slops, but prove
it to cur face

The Widow’s Uniforms is not the soldier man’s
disgrace,

For it’s “ Tommy this, an’ Tommy that,” an’ “ Chuck
him out, the brute!”

But it’s “ Savior of ’s country” when the guns
begin to shoot;

An’ it’s “Tommy this, an’ Tommy that, an’ any-
thing you please”;

An’ Tommy ain’t a bloomin’ fool — you bet that
Tommy sees!

Self-Discipline

In this era when we have a national debt of al-
most three hundred billion dollars, when state and
local governments as well as the colossus in Wash-
ington are seeking more and more ways to raise
money for essential or non-essential spending, and
when installment buying has become an endemic
disease, thrift and hard work somehow are no
longer regarded by most people as basic virtues.
It therefore is encouraging, once in a while, to find
young people who recognize the wisdom of living
within their incomes and of actually saving some
money.

For that reason, the remarkable wisdom and
judgment of a young couple whom we know must
certainly deserve a paragraph or two. Mary is 28,
and a busy, happy wife and mother. Dick is 30, a
young scientist on a modest salary — an ambitious,
hard working and realistic young man. They have
two children, five and seven years of age. They
are buying their home on monthly installments, a

366

Journal of Iowa Medical Society

June, 1962

modest three-bedroom house in an area of un-
pretentious homes. A few months ago Mary re-
ceived a bequest of half a million dollars. After
much thought and discussion, the young people
decided to invest the inheritance and to use neither
the principal nor the income until they reached
their mid-forties.

They arrived at their unusual decision for
several reasons. It was their mutual feeling that
having more money to spend could not increase
their happiness. Loss of incentive would unques-
tionably jeopardize Dick’s career. Affluence could
have an adverse effect upon their children and
lead them to adopt values that their parents con-
sider undesirable. Additional spending money
would not add to the deep affection, the firm dis-
cipline and the sound values that already exist in
their home.

Governmental agencies and other families might
well emulate Mary and Dick. Money in large
quantities is no guarantee of happiness. Affluence
does not assure character. An orgy of spending
does not buy friends. Old-fashioned conservative
virtues still have merit.

Abdominal Surgery in
Geriatric Patients

The significance of chronologic age upon the
mortality of abdominal operations in geriatric pa-
tients has recently been analyzed by Stahlgren.*
In his series, 102 patients over 69 years of age
underwent 111 extensive operations. Gynecologic,
urologic and orthopedic cases were excluded from
the study group. There were 36 operations on the
colon and rectum, 9 on the biliary tract, 12 upon
the stomach, 4 for obstruction of the small intes-
tine, 46 for herniorrhaphy, 2 for appendectomy and
2 for miscellaneous indications.

There were 94 survivors in the group of surgical
patients, and thus the over-all mortality in the 111
operations was 15.3 per cent. The mortality rate
for emergency operations was 2% times the mor-
tality rate for non-emergency surgery.

The author concluded that chronologic age in
itself is not an important factor in the mortality
rate. The serious nature of the primary disease in
a person of advanced age is the most important
factor affecting the outcome of abdominal oper-
ations.

With the increased longevity of the older age
group, it is becoming increasingly important to cor-
rect surgical defects in the upper ranges of middle-
age. Certainly no patient should be permitted to
take a hernia, gallstones or an enlarged prostate
into old age. It is only by such foresight that the
high incidence of emergency operations, with their

*Stahlgren, L, H.: Analysis of factors which influence

mortality following extensive abdominal operations upon
geriatric patients, surg., gynec. & obst., 113:283-292, (Sept.)
1961.

attendant high mortality, can be significantly re-
duced.

Ulcerative Colitis in Children

If there ever was any doubt about the serious-
ness of ulcerative colitis, a recent report from the
Mayo Clinic* on the prognosis of the disease in
children should convince the skeptic. It is a follow-
up study of 427 children less than 15 years of age
when diagnosed, who were observed from 1918
to 1959. The mean age at the time of diagnosis had
been 11.1 years, and the diagnosis had been con-
firmed by roentgenograms or proctoscopy, or both.
Twenty-six patients had been lost to follow-up, and
the status of each of the remaining 401 patients
was determined as of January, 1961.

The study revealed that 112 of the 401 patients
had died. Of the 112 fatalities, 40 had succumbed
to carcinoma of the colon, and 57 to other diseases
related to ulcerative colitis. Survival rates for the
401 patients, calculated by actuarial methods at 5,
10, 15 and 20 years, were 89.2, 80.8, 66.4 and 58.9
per cent, respectively. The calculated survival rate
for normal children having a mean age of 11.1
years was 97.9 per cent.

Carcinoma of the colon or rectum had developed
in 46 patients, and intermittent symptoms of
chronic ulcerative colitis had been present in 39
of them until carcinoma was detected. Of the 46
patients who had developed carcinoma, 40 had died
from the malignancy. Six patients treated by
colectomy and ileostomy were still living eight
years after their operations. One patient had de-
veloped carcinoma at 10 years of age, after seven
years of active disease. Thirty-seven of the 46 pa-
tients had developed carcinoma before the age of
31 years. The mean interval from the time of diag-
nosis of chronic ulcerative colitis to death from
carcinoma had been 14.8 years, and 33 patients
had died between seven and 20 years after the
onset of colitis. By contrast, among 401 unselected
children between one and 14 years of age, less
than one death from any malignant neoplasm could
have been expected. The duration of the ulcerative
colitis appeared to have been an important factor
in the development of carcinoma.

A major operation had been performed on each
of 85 patients at some time during the course of
the disease. Total colectomy with ileostomy had
been done in 48 patients. Thirty-one of 36 patients
in whom cancer had not developed were improved
at the time of the follow-up study, after periods
ranging from six months to 17 years; one had im-
proved; and four of the group had died. Twelve
patients with carcinoma of the colon also had
had colectomy and ileostomy, and six were living
at the time of the follow-up study. Five patients
had had subtotal colectomy and ileostomy; three

*Michener, W. M., Gage, R. P., Sauer, W. G., and Stickler,
G. B.: Prognosis of chronic ulcerative colitis in children.
new England j. med., 265:1075-1079, (Nov. 30) 1961.

Vol. LII, No. 6

Journal of Iowa Medical Society

367

patients without carcinoma were improved; in
the other two, carcinoma of the rectal stump had
developed six and 17 years after operation, and
both patients had died. More limited operations
had been carried out in 32 patients for palliative
reasons, and of them 27 had died.

Just 126 of the patients were thought to be
asymptomatic at the time of the follow-up study.
In the present state of knowledge, according to the
investigators, the clinical course of the patient does
not permit a prediction as to whether chronic
ulcerative colitis will give rise to carcinoma in any
particular instance.

From this experience it would appear that total
colectomy and ileostomy offer a promising method
of management, but the authors admonish that
this implication must be interpreted with caution.
The operation is not without risk, the complica-
tions of ileostomy are numerous, and a longer
follow-up period will be necessary before definite
conclusions can be drawn in this regard. The fact
that 126 out of the 401 patients were asymptomatic
at the time of the study explains the reluctance of
the surgeon to subject these unfortunate children
to such a serious operation.

Again, Carcinoma of the Breast

For some 60 years, the accepted treatment for
carcinoma of the breast has been radical mastec-
tomy. First in 19491 and again in 1955, 2 McWhirter,
the Edinburgh surgeon, challenged the method of
radical excision and reported the results of an ex-
tensive experience with simple mastectomy and
radiotherapy in the treatment of cancer of the
breast. The subject has been controversial ever
since, and though the two methods of treatment
have been compared in numerous contributions to
the literature, no controlled or blind study has
been made.

In the past year, George Crile, Jr.3 has reported
upon the simplified treatment of cancer in a rel-
atively small series of patients operated upon be-
tween 1953 and 1957. From this experience, Dr.
Crile concludes that in the treatment of Stage 1
cancer of the breast, simple mastectomy without
prophylactic radiation appears to be at least as
effective as radical mastectomy with or without
radiation. However, the patients have been fol-
lowed for only three years. In the patients with
Stage 1 cancer who were treated by simple mas-
tectomy without radiation and in whom the disease
later reappeared in the axillary nodes and was re-
moved by axillary dissection, the chances for sur-
vival of the patient do not appear to be any less
than in individuals on whom radical mastectomy
was done initially. In favorable Stage 2 cancer,
modified radical mastectomy with preservation of
the muscles and without radiation therapy seems

to be as effective as any other treatment or com-
bination of treatments. Dr. Crile states: “The suc-
cess of simple treatments is well enough estab-
lished that controlled clinical studies can now be
made without fear of doing an injustice to the pa-
tients receiving the simpler treatments.”

He goes on to say, “The interplay between the
good and the bad of various types of treatment
makes it difficult to decide how to treat the indi-
vidual patient. ... I do not know the best method
of treatment. . . . Our figures do not show any
superiority of one method of treatment over
another. . . . What is needed now is a series of
carefully planned blind experiments in which all
factors except the type of treatment are the same.”
Thus it seems apparent that Dr. Crile is not recom-
mending abandonment of radical mastectomy, but
rather has reported impressions gained from an
exploratory effort to evaluate the merit of simple
mastectomy in the treatment of carcinoma of the
breast.

Quite in contrast to the concept so energetically
championed by McWhirter and to the conciliatory
attitude expressed by Crile, another surgeon,
O. Theron Clagett, having reviewed some 9,000 pa-
tients who have had radical mastectomies for
cancer of the breast at the Mayo Clinic, stands
resolute and emphatic in support of that procedure
for the treatment of the disease. A recent paper
that he has written on the subject concludes with
the following paragraph:4

“The treatment of carcinoma of the breast is a
controversial subject. I realize the inadequacies
of radical mastectomy as well as anyone. I want
methods of treatment that are better and more
effective than radical mastectomy as much as any-
one, and I hope that when more effective treat-
ment becomes available I will be among the first to
recognize it and use it. I thoroughly approve of the
dissatisfaction with radical mastectomy that is ap-
parent. It is always healthy to be dissatisfied and
to seek something better. However, in my opinion,
at the present time classic, radical mastectomy
still provides the most effective treatment that can
be offered to patients with carcinoma of the breast.
Hormone therapy, chemotherapy and irradiation
may be added to radical mastectomy under ap-
propriate circumstances. Efforts to treat patients
having carcinoma of the breast by simple mastec-
tomy or any other abbreviation of classic, radical
mastectomy is a backward step and should be con-
demned.”

REFERENCES

1. McWhirter, R.: Treatment of cancer of breast by simple
mastectomy and roentgenotherapy. Arch. Surg., 59:830-842,
(Oct.) 1949.

2. McWhirter, R.: Simple mastectomy and radiotherapy in
treatment of breast cancer. Brit. J. Radiol., 28:128-139,
(Mar.) 1955.

3. Crile, G., Jr.: Simplified treatment of cancer of breast:
early results of clinical study. Ann. Surg., 153:745-761,
(May) 1961.

4. Clagett, O. T.: Treatment of carcinoma of breast: con-
troversial subject. Missouri Med., 59:25-30, (Jan.) 1962.

368

Journal of Iowa Medical Society

June, 1962

President’s Page

It is not enough for us merely to oppose all
schemes for attaching health care to Social Security.
Rather, we must present an alternative that will do
two things: (1) measure the need for medical aid to
the aged; and (2) establish an economical program
for meeting that need. In Iowa, we have such an
alternative.

Following the defeat of the King-Anderson Bill,
the obtaining of funds for the implementation of
the Kerr-Mills Act must be the Number 1 objective
of the Iowa Medical Society.

It won’t be easy. As was true in getting the Kerr-
Mills Implementation Act onto the books, the IMS
will probably have to take the lead in requesting
funds to put the 1961 law into effect.

President

Micturition Syncope:

Reports of Two Cases

R. OVERTON, M.D., Des Moines

Recently, I have had occasion to study two pri-
vate patients in whom syncopal attacks had oc-
curred during micturition. Both were young male
adults who thought themselves to be in good health
and hadn’t been frightened, in the least by their
experiences. Neither had a history of syncope un-
der any other circumstances, and each of them
was brought to my attention by his worried wife.

CASE I

Mr. H. D. G., who is 32 years of age, got up to
go to the bathroom about IV2 hours after going to
bed, and fainted, hitting his head on the bathtub
as he fell to the floor. His wife found him there,
incontinent, biting his tongue, moderately cyanotic
and exhibiting rhythmical but irregular move-
ments of the jaw and twitching of the hands. He
remained in that state for about five minutes, and
afterward had a feeling of dizziness and weakness
for an hour or two. He did not, however, have per-
sistent headaches, nor did he fall into a deep sleep.

He had had one previous attack, five years ago.
There was no history of alcoholic intoxication. His
past medical history was negative. Before each
attack, he had eaten a bag of chocolate-chip cook-
ies. The first occurrence had taken place six
hours before he went to bed.

Physical examination revealed a 32-year-old
white male of mesomorphic body build, in no
acute distress and currently in good health. All
findings were essentially normal. His blood pres-
sure was 128/70 mm. Hg, and his pulse was 76/min.
He was obese, especially through the abdominal
walls. The deep tendon reflexes and the neuro-
logical examination were normal.

We felt that perhaps the syncopal attack might
have represented an epileptic type of seizure, an
organic brain syndrome, or a consequence of cir-
culatory changes of one variety or another in the
brain. A neurosurgeon saw the patient in con-
sultation, and he felt that there was no evidence
of increased intracranial pressure. An internist
who also saw him felt that the EKG findings indi-
cating myocardial ischemia on the anterior surface,

with moderate involvement, were not characteris-
tic of true organic heart disease but were the con-
sequence of a convulsive seizure, and thus that
the syncopal attack had not been on the basis of
a cardiovascular disease.

The patient’s transaminase was 15 units/ml,
and his sedimentation rate was 7 mm./hr. His spinal
fluid showed no microorganisms. The colloidal
gold curve was 0122210020. The calcium was 9.8
mg. per cent; the BUN 9.7 per cent; the sodium
138 mEq./L.; the inorganic phosphorus 4.6 mg. per
cent; and the potassium 4.6 mEq./L. The spinal
fluid chlorides were 131 mEq./L. and the total
protein was 72 mg./lOO ml. The urinalysis was es-
sentially negative, except for a slight trace of al-
bumin. The complete blood count was normal. The
protein-bound iodine was 5.9 meg. per cent.

A chest x-ray was normal, except that the heart
size was at the upper limit of normal, and the im-
pression was of a hypertensive contour heart. The
cervical spine was normal, and the skull films
were normal. Serial electrocardiograms indicated
an unusually large P wave and minor changes in
the T waves suggestive of minor myocardial
changes or drug effects. However the serial trac-
ings revealed that these findings were of a tran-
sient nature. An electroencephalogram was nor-
mal.

When the patient was seen a second time, for a
follow-up examination and evaluation, his blood
pressure was normal and the physical findings
were likewise normal, except for his moderate
obesity. The Wassermann reaction was negative,
and the glucose tolerance curve was normal.
There was no hypoglycemia. A repeat spinal fluid
examination revealed a cell count of 5/cu. mm.,
color clear, and total protein 43 mg. per cent. A
urinalysis and a complete blood count were again
normal. A pneumoencephalogram was interpreted
as follows: “Spinal canal shows fairly good visual-
ization of the ventricular system, and it is in its
normal position. There is some asymmetry of the
ventricular system, with the left being somewhat
dilated as compared with the right, but no definite

369

370

Journal of Iowa Medical Society

June, 1962

evidence of intracranial pathology, such as a neo-
plasm, can be seen.”

The patient’s blood pressure was 150/90 mm. Hg
when he was lying down, and when he stood erect
it dropped to 116/84 mm. Hg. His pulse was
84/min. Other readings were taken with the pa-
tient in various positions, following vigorous exer-
cise, and at rest, but none of the readings fell
outside of the range represented by the figures
just quoted, and the patient experienced no syn-
copal attacks.

Final diagnosis: syncope.

CASE 2

Mr. D. M., age 23, had a seizure in the bathroom
of his home at 3:00 a.m., after rising to micturate.
He says he had had six previous attacks, all oc-
curring during micturition at night. The first oc-
curred when he was 16 years of age. He had not
been drinking or over-indulging in food at bed-
time.

The patient states that though he doesn’t re-
member the circumstances of his previous attacks,
on this most recent occasion he had had a heating
pad on his back for several hours to relieve pain
due to back strain. He remembers “bearing down”
to speed his urination. His wife says that he was
pale and sweaty when she found him, and that
she noted some moderate discoloration and some
slight, jerky motions of his extremities during
the attack. The whole episode lasted about three
minutes, and afterward he felt only “tired.” His
back, of course, was sore, as it had been previously.

A complete physical examination was performed,
and all his sensations were found to be intact. The
following studies elicited findings that were judged
to be within normal limits: calcium 10.2 mg. per
cent, total cholesterol 150 mg. per cent, inorganic
phosphorus 3.8 mg. per cent, potassium 4.6 mEq./L.,
sodium 146 mEq./L., BUN 19 mg. per cent, uric
acid 4.0 mg. per cent. A complete blood count, a
urinalysis, a glucose tolerance and a protein-
bound iodine determination were all normal.

Skull films, an electrocardiogram, an encephalo-
gram and intravenous pyelograms were done. A
lumbar puncture showed normal pressure, chloride
126 mg. per cent, glucose 68 mg. per cent, and
protein 45 mg.

The patient says he knows when he is going to
have an attack, for he feels hot, but his impres-
sion may be the result of a chain of coincidences.
On the most recent occasion he had had a heating
pad against the lumbar portion of his back, and
on other occasions the weather may have been hot.
He also stated that each time he has had an attack,
he has been worried about some problems, espe-
cially his financial position and his employment.

DISCUSSION

The syncopal syndrome is well known to all
physicians, and is seen under many and varied

circumstances. It has been described as accom-
panying many otherwise unrelated conditions. The
simple faint, called vaso-depressor syncope, is
often seen in association with bad news, fear, the
sight of blood, etc. Ordinarily, the cardiac output
is well maintained in the fainting reaction,1 and
this seems to be its characteristic feature. Syncopal
attacks also occur with the carotid sinus depressor
reflex and vaso-vagal stimulation; postural hyper-
tension; diabetic neuropathy, tabes dorsalis and
bilateral sympathectomy; cardiac conditions such
as Adams-Stokes; external compression of the
thorax with the glottis closed; hypoglycemia; and
febrile illnesses.

In the two patients presented here, the pre-
disposing factors seem to have been quite diverse,
if one can judge from the histories that they gave.
Both were apparently in good health at the time
of onset. One of them said that both of his attacks
had occurred several hours after he had eaten a
considerable number of chocolate-chip cookies. He
is convinced that there must have been a cause-
effect relationship between the two events, and
has resolved to eat no more of that type of food.
The other patient associates heat with his attacks,
and has also noted that each attack has occurred
at a time when he was under some emotional stress
and worry.

Syncope during micturition has recently been
studied as a separate entity by several investi-
gators, and the following is a brief summary of
articles about it that have appeared in the recent
literature.

Lamb and Dermksian2 have suggested lack of
sleep, lack of food, consumption of alcohol, a warm
environment and fatigue as possible etiologies.
Lyle, Monroe, Flinn and Lamb, in a report of 24
cases of this syndrome, found “alcoholic ingestion
in 14 of the 24 attacks as the most common pre-
disposing factor.”3 In 1960, Eberhart and Morgan
presented a case of syncope associated with mic-
turition and hematuria from a calculus that was
felt to have been irrelevant. The patient also had
a vesicle-neck obstruction which was corrected.
They felt that “the actual problem is a functional
bladder-neck obstruction which results in the use
of the Valsalva maneuver to induce voiding.”4

At this point, a brief description of the Valsalva
maneuver may be appropriate. I quote from an
article by George B. Prozan and Allen Litwin:

“The dynamics of Valsalva’s maneuver have
been described by several investigators and have
been divided into four phases. Phase I begins with
the onset of straining and consists of a rise in
blood pressure associated with a forceful expulsion
of blood from the lungs into the left side of the
heart, increasing cardiac output. This rise in blood
pressure is followed shortly by a marked fall,
which is the beginning of phase II. Phase II con-
tinues until the release of the strain and is mani-
fested by a narrow pulse pressure with a rising

Vol. LII, No. 6

Journal of Iowa Medical Society

371

diastolic pressure resulting from the precipitous
fall in cardiac output and the concomitant rise in
peripheral resistance. Upon release of the strain —
the beginning of phase III — the dynamics of phase
II are exaggerated due to the absorption of the
right ventricular output by the sudden expansion
of the previously compressed vascular tree of the
lungs, which momentarily decreases further the
venous return and output of the left ventricle.
Phase IV follows immediately with a seemed rise
in blood pressure above control levels, a conse-
quence of the increasing cardiac output and the
maintenance of the increased peripheral resistance.
This is the so-called “over-shoot.” This blood
pressure elevation activates the carotid sinus and
the aortic arch reflexes, which cause a diminution
in peripheral resistance and a bradycardia.”7

William Proudfit and Mario Forteza reported
on seven cases of micturition syncope, in 1959, in
patients ranging in age from 16 to 37 years. All
of the attacks had occurred after prolonged re-
cumbency. The authors had studied the Valsalva
effect and felt that the maneuver is performed at
the start and cessation of urination in men. They
explained that because the trunk is less muscular
in women, the Valsalva maneuver is less effective,
and also that the position which women assume
during micturition makes them less affected by
any resultant anatomic changes. Their explana-
tion for the syncope was that it “results from the
circulatory effects of the Valsalva maneuver per-
formed while the patient is urinating, at a time
when the venous return to the heart and the
peripheral resistance are low.”5

McGee,6 in a study of two cases of micturition
syncope, agreed with Proudfit and Forteza and
explained that the fall in blood pressure and the
rise in intracranial extravascular pressure after
recumbency and during the Valsalva maneuver
creates temporary ischemia with resulting syn-
cope.

Prozan and Litwin7 also presented three cases
of syncope following micturition. One of the pa-
tients had been found in a shock-like state, with
atrial fibrillation, a high degree of A-V block,
ventricular premature beats and bradycardia. The
second patient had T-wave changes suggestive of
injury to the posterolateral wall. The changes per-
sisted for a few hours after the syncope, and then
disappeared spontaneously. The third patient, fol-
lowing micturition, had fainted while turning his
head toward the bathroom light and reaching to
turn it off.

Prozan and Litwin asked 20 individuals to per-
form experimental Valsalva maneuvers, but in
only one of them were there the EKG changes
that had been found in the three patients. These
changes were in the T wave, sinus arrest and
nodal rhythm of cardiovascular instability.

The authors felt that although micturition syn-
cope has been thought to be a manifestation of

phase II of the Valsalva maneuver, with the fall of
cardiac output during strain, that post-micturition
syncope occurs in phase IV, when sensitization of
the myocardium by anoxemia can build up acetyl
choline to cause cardiac standstill and other ar-
rhythmias.

Another interesting concept regarding the
physiologic dynamics of the syncopal syndrome
can be found in a study by Lyle, Monroe, Flinn
and Lamb. Their studies of cardiovascular status
did not indicate significant changes in myocardium.
It is their hypothesis that the emptying of a dis-
tended bladder can cause a reflex type of syncope:

“In persons assuming the upright posture with
a distended bladder, reflex vasoconstriction may
obviate the usual drop in blood pressure of 5 to
20 mm. that stimulates carotid-sinus and aortic-
adaptive mechanisms. On voiding, this reflex vaso-
constriction may be released with concomitant
fall in pressure. However, in this situation the
postural-adaptive mechanisms are not allowed the
usual period of adjustment afforded while the
person gradually arises by first sitting. Instead,
the compensatory reactions must take place while
he is already erect and standing motionless. In the
presence of predisposing factors lowering periph-
eral arterial resistance — for example, recumbency
and alcohol intake — the adaptive mechanisms may
occasionally fail, with resulting circulatory col-
lapse.”3

CONCLUSION

Two cases of micturition syncope have been re-
ported. Both were in young, healthy males. One
patient had overindulged in food prior to each
episode. The other felt that heat and anxiety had
played roles in his difficulties. Both exhibited an
apparent lack of concern regarding their condi-
tion. One had EKG findings suggesting some myo-
ischemia for a few hours afterward.

The possible etiology has been discussed, and
the literature on the subject has been summarized.

REFERENCES

1. Stead, Eugene A., Jr.,: “Fainting.” In: MacBryde. C. M.,
ed.: Signs and Symptoms, Third Edition. Philadelphia, J. B.
Lippincott Co., 1957. Chapter XXVII. pp. 665-678.

2. Lamb, L. E., and Dermksian. G.: Syncope in population
of healthy young adults; incidence, mechanisms and signifi-
cance. J.A.M.A., 168:1200-1207, (Nov. 1) 1958.

3. Lyle, C. B., Jr., Monroe, J. P. H., Flinn, D. E., and
Lamb, L. E.: Micturition syncope; report of 24 cases. New
England J. Med., 265:982-986, (Nov. 16) 1961.

4. Eberhart, C., and Morgan, J. W.: Micturition syncope;
report of case. J.A.M.A., 174:2076-2077, (Dec. 17) 1960.

5. Proudfit, W. L., and Froteza, M. E.: Micturition syn-
cope. New England J. Med., 260:328-331, (Feb. 12) 1959.

6. McGee, R. R.: Micturition syncope; report of two cases.
South. M. J., 52:1076-1077, (Sept.) 1959.

7. Prozan, G. B., and Litwin, A.: Post-micturition syn-
drome. Ann. Int. Med., 54:82-89, (Jan.) 1961.

Attend the

AMA ANNUAL MEETING
McCormick Place, Chicago
June 24-28

Hearing CcnJeriaticn

Definition of a Hearing
Conservation Program

The Committee on the Conservation of Hearing
for the State of Iowa, which is presenting a series
of articles in the journal, consults with and ad-
vises all agencies interested in the problems of
hearing impairment. Its services are available to
industry , agriculture, education and to the broad
spectrum of public health and welfare services
within the state.

The Committee has been officially sponsored by
the Iowa State Department of Health since 19 57.
However it was first formed in 1949, and has been
continuously active under the leadership of Dr.
Dean M. Lierle, head of the Department of Oto-
laryngology and Maxillofacial Surgery at S.U.I.
From the first, the Committee has been interdis-
ciplinary in composition and purpose.

The Committee presently consists of representa-
tives* from the section on otolaryngology of the
Iowa Medical Society, from the Academy of Oto-
laryngology and Ophthalmology , from the Amer-
ican Academy of General Practice, from the State
Department of Health, from the Department of
Otolaryngology and the Department of Speech
Pathology and Audiology at S.U.I. , from the Divi-
sion of Special Education of the State Department
of Public Instruction, from the Iowa School for
the Deaf, and from the Des Moines Chapter of the
American Hearing Society.

Before attempting to state what a hearing con-
servation program is, or should be, it seems appro-
priate for us to call attention briefly to a few im-

*C. M. Kos, M.D. (chairman), otologist in private practice,
Iowa City.

Joseph Wolvek (executive secretary), consultant. Hearing
Conservation Services, State Department of Public Instruc-
tion, Des Moines.

L. E. Berg, superintendent, Iowa School for the Deaf,
Council Bluffs.

Dale S. Bingham, consultant. Speech Therapy Services,
State Department of Public Instruction, Des Moines.

Paul Chesnut, M.D., private practitioner and member of
AAGP, Winterset.

James F. Curtis, Ph.D., head, Department of Speech Pa-
thology and Audiology, S.U.I., Iowa City.

Madelene M. Donnelly, M.D., director. Division of Maternal
and Child Health, State Department of Health, Des Moines.

Joseph Giangreco, assistant superintendent, Iowa School for
the Deaf, Council Bluffs.

Malcolm Hast, Ph.D., Department of Speech Pathology and
Audiology, S.U.I., Iowa City.

William Ickes, Ph.D., director, Des Moines Hearing and
Speech Center, Des Moines.

Byron Merkel, M.D., otolaryngologist in private practice
and member of Academy of Otolaryngology and Ophthal-
mology, Des Moines.

William Prather, Ph.D., Department of Speech Pathology
and Audiology, S.U.I., Iowa City.

Mrs. Jeanne Smith, Department of Otolaryngology and
Maxillofacial Surgery, S.U.I., Iowa City.

Edmund Zimmerer, M.D., commissioner, State Department
of Health, Des Moines.

portant facts about hearing and hearing impair-
ment.

One of the most fundamental of these facts is
that hearing involves much more than the ability
to detect the presence of sound and to attach some
significance to various kinds of sounds. More sig-
nificant than all else is the fact that a reasonably
intact sense of hearing is required for an individual
to communicate normally with his fellows. It has
often been said that man’s most distinctive char-
acteristic— indeed the essence of his humanness —
is his ability to make contact with the minds of
his fellows by means of linguistic communication.
Because a significant hearing impairment inev-
itably interferes with communication through lan-
guage, it strikes at something which is very deep
and vital, with an emotional impact and with
undercurrents that are deeply disturbing.

A second fundamental fact of particular impor-
tance where children are concerned is that much
of what we learn comes to us through the sense of
hearing. Hence, a significant impairment of hearing
presents a very serious educational handicap.

Third, a hearing handicap differs very impor-
tantly from almost every other kind of crippling
condition in that it does not “show” in the way
that paralysis or blindness “shows.” Thus, a per-
son’s failure to respond, or his inability to under-
stand, is sometimes mistakenly interpreted as in-
attentiveness, as intellectual dullness or as deliber-
ate intractableness, and may arouse irritation or
impatience rather than sympathy.

There are, of course, other facts about hearing
impairment that might be discussed, but an appre-
ciation of these few will provide a backdrop against
which to consider what the essentials of a hearing-
conservation program should be. Taken literally,
the term hearing conservation is a misnomer, for
it is much too limited in its implications. The im-
portant goals of a hearing-conservation program
include detection, prevention of hearing impair-
ment, restoration of useful hearing to persons who
have incurred losses, and rehabilitation whenever
possible. Fortunately, modern-day medicine has
much to contribute to the prevention of hearing
loss and to the restoration and conservation of
hearing ability.

A comprehensive hearing-conservation program
goes much farther. It is concerned not only with
conserving hearing but with the conservation of

372

Vol. LII, No. 6

Journal of Iowa Medical Society

373

the individual who has a hearing problem. It is
concerned with conserving his ability to communi-
cate despite his hearing handicap, with reducing
the educational handicap of the child who hears
less well than his fellows, and with helping each
person who suffers from impaired hearing to de-
velop and maintain his maximum potential as a
happy, useful, contributing individual.

These, then, are the broad goals of a hearing
conservation program. The Committee on the Con-
servation of Hearing for the State of Iowa func-
tions as an advisory group working for the achieve-
ment of these objectives. It finds and recommends
appropriate procedures, and helps to coordinate
the efforts of various persons and agencies that
work directly with hearing problems.

SEVEN STEPS

A comprehensive hearing-conservation program
should include the following: (1) public educa-

tion, (2) adequate case finding, (3) adequate audi-
ological and medical diagnostic examinations, (4)
medical and surgical treatment as indicated, (5)
adequate audiologic reevaluation and consulta-
tion, (6) special educational and reeducational pro-
cedures (according to the needs of the individual),
and (7) special vocational rehabilitation and
guidance.*

Each of these steps is important in the over-all
program, although the special significance of each
will vary with individual cases. Public education
can hardly be overstressed. Experience provides
ample demonstration of the need for more wide-
spread knowledge and understanding of hearing
problems. There is too little recognition of the
frequency and seriousness of hearing handicaps, too
little recognition of what can be done to prevent
hearing impairment, too little understanding of
what can be done to reduce the handicapping ef-
fects of hearing impairment, and too little infor-
mation concerning the available sources of help. It
is unfortunate but true that this lack of adequate
knowledge and understanding is not confined to
“the lay public” but includes professional people
in the fields of health and education. Most to be
deplored is the fact that attempts to institute ef-
fective hearing-conservation procedures have some-
times been thwarted, or made less effective, by a
lack of understanding on the part of professional
people and groups, and particularly by a lack of
mutual understanding of the proper and important
roles that different professional groups can play
in a comprehensive hearing-conservation program.

The need for adequate case finding is self-evi-
dent. It is to be emphasized that this step is the
very crux of the preventive aspects of any hear-
ing-conservation program. It is, perhaps, too little
understood that much can be done to prevent
permanent loss of hearing, and even to reverse

* These seven steps are basically the same as those stated
in Hardy, W. G.: Children With Impaired Hearing. Children's
Bureau Publication No. 326, 1962.

hearing impairment in some cases, provided that
the incipient hearing impairment can be detected
early enough.

One of the best means of discovering early evi-
dence of hearing impairment consists of the school
hearing surveys that are carried on under the
supervision of the Division of Special Education of
the State Department of Public Instruction. When
these surveys are well conducted, they can be a
highly valuable part of a hearing-conservation pro-
gram. Case finding must be coordinated with ade-
quate diagnostic examinations and medical and
surgical treatment as indicated. Only when this
coordination is accomplished can the full potential
for prevention of hearing handicaps be realized.
Adequate audiologic reevaluation and consultation,
special educational and reeducational procedures
(according to the needs of the individual), and
special vocational rehabilitation and guidance are
primarily concerned with the measures which can
and should be taken to minimize the handicapping
effects of a hearing loss which cannot be reversed
by medical or surgical treatment. As previously
indicated, this is an extremely important phase of
hearing conservation, and each of these steps is de-
serving of much fuller discussion than has been
possible in this first article. Each of them will be
given more detailed treatment in subsequent dis-
cussions to appear on these pages.

THE PHYSICIAN'S RESPONSIBILITY

We do hope that doctors will not feel that be-
cause these steps do not involve medical or sur-
gical treatment directly, they are outside of the
physician’s immediate concern. There will be lit-
tle argument with the point of view that a physi-
cian’s obligation to his patient includes getting
him to seek the nonmedical habilitative and reha-
bilitative help that will enable him to realize his
maximum potential. To do this, the physician must,
of course, have information concerning what can
be accomplished by reevaluation, reeducation and
rehabilitation, and concerning the agencies to
which patients can be referred for such help.

American Medical Women's
Association

The American Medical Women’s Association
extends an invitation to all women physicians at-
tending the AMA annual meeting in Chicago to
be its guests at a brunch on Sunday, June 24, at
11:00 a.m. at the Essex Inn. A panel will discuss
the topic “Medical Woman Power: Can It Be
Used More Efficiently?” and audience participation
will be welcomed.

Those who wish to attend are asked to notify
the Association, at 1790 Broadway, New York 19,
no later than June 22.

Program of the Woodward State
Hospital and School

W. C. WILDBERGER, M.D., Acting Superintendent

One cannot get logically into a discussion of
programs or program development for the men-
tally retarded until or unless he brings basic phi-
losophy to mind. For that reason, I should like to
preface the program outline of the Woodward
State Hospital and School by making a series of
skeleton statements about the basic philosophy that
is current there.

1. We are operating on the principle that a child
has certain rights — rights to care, maintenance,
educational training and medical attention, to name
a few. His parents have a responsibility to provide
those things to him, sometimes unaided and some-
times with the help of the local community, school
district, city, town, township, county or state. For
the ordinary child, this philosophy has been prac-
ticed, but for the retarded child, it has not been
followed.

2. Natural parents have legal rights that they
can expect will be implemented for their children’s
welfare under common and statutory law. With
these rights should go some obligations. It is our
belief that parents and communities should not
present a retarded child to the state with the ex-
pectation that since he is handicapped he will be
given lifetime care. It is our belief that we at
Woodward should take the problem of the retarded
individual and should help to correct it — to im-
prove, habilitate, treat or manage the individual —
for a short, intermediate or moderately long period
of time, but that then we should return the indi-
vidual to his parents, community, job, local special-
education class, nursing home, foster home, fam-
ily, etc. for continuing definitive care, as needed,
after he has derived as much benefit as he can
from the hospital-school.

3. It is our belief that retarded persons should
be salvaged for community living in the natural
family home, foster home or family-care home —
i.e., in the social unit that will best meet his needs.
This salvaging of human beings should go on be-
fore admission, after admission, throughout their
stay at the institution, and at whatever other time

their particular needs and potentials become evi-
dent.

4. The retarded person is at least as much a
product of what we make him, or let him become,
as he is the product of his meager intellectual,
neurologic or functional endowment.

5. The financial investments in properly special-
ized training, education, medical care, habilitation
and vocational placement are much more impor-
tant to these people than monetary grants could
be, for with training and habilitation these retard-
ed persons will become, to a degree at least, self-
sufficient and productive.

6. Failure to recognize the retarded as people
who need multiple orientations and care facilities
has tended to push all of them together under one
roof, with consequent overcrowding. We now rec-
ognize that some of them need hospital schools and
others need nursing home care, custodial home
care, the facilities that county homes provide,
foster homes, family homes, day-care facilities,
sheltered workshops, etc.

7. A heterogenous population with heterogenous
problems has been proverbial in an institution for
the retarded. People with multiple handicaps, by
default, have become a large part of the popula-
tions of most such institutions because they have
fitted into no specialized facility.

8. Overcrowding, long waiting lists, limited qual-
ity of service — these historically have character-
ized public institutions for the retarded. Their re-
sources have been strained to the breaking point
by the large numbers of people admitted to them,
and attractive salaries for staff members and
worthwhile programs for patients have been im-
possible.

PROGRAMS AND PROGRAM DEVELOPMENT

A crash program of current evaluation and re-
evaluation of patients has been started at Wood-
ward. For that purpose, the hospital was divided
into four areas and the team approach was adopted.
The following were assigned as team members: a

374

Vol. LII, No. 6

Journal of Iowa Medical Society

375

physician, a psychologist, a social worker, an edu-
cator (academic or vocational, depending upon the
age level of patients in the area), a nurse, a recrea-
tion worker, and an attendant. Each such team has
its office in a place outside the area with which it
is concerned. This arrangement put professionals
at once in closer clinical contact with patients in
four sub-areas. Improved communication and un-
derstanding of patient evaluation and care has
come about. Each of the four teams has its respon-
sibilities, and thus both personnel and patients
have become actively motivated.

With patients reevaluated currently and seen
daily by a representative of each of the discip-
lines, a dynamic movement toward out-placement
began. Admission of new patients followed. The
outflow currently exceeds the influx, and as of
March 5, 1962, the resident population has been
realistically reduced. Everybody has gained. Pa-
tients who had been at the institution for long
periods of time and whose needs can be met satis-
factorily elsewhere have been placed out; those
on the waiting list have been admitted; overcrowd-
ing has been reduced; and the professional help
that the budget allows us to employ can now give
more individualized and specialized care, treatment
and management to each patient.

A redefinition of patients has been started on
the basis of functional levels by age, IQ, physical
ability, motivational state, etc. With all factors
taken into consideration, the patients can be visu-
alized as on rungs of a ladder, making progressive
steps upward as they evolve in age, education,
training, etc.

The institution is becoming a therapeutic com-
munity in the modern sense. An over-all psychi-
atric, therapeutic, adjustment, training atmosphere
is permeating the whole staff as well as the pa-
tients, to the benefit of all concerned. The grounds
have taken on the appearance of a dynamic cam-
pus. A central dining room was set up for all phys-
ically able patients, and consequently the patients
have been given a greater opportunity for move-
ment. Boys and girls walk there in good weather,
and are transported there and back in busses when
the weather is inclement. It is truly remarkable
how much this physical activity has stimulated
mental activity.

Training has been given a broad interpretation
at Woodward State Hospital and School. At the
simplest level, training means instruction in self-
help and thus is psychomedical and neuromuscular.
The child who has lain in bed is taught to sit up,
stand and walk, the concept being that the more
independent the patients can be made, the less
attention they will need from the nursing attend-
ants. Physical therapy, nursing care, etc. take the
major roles in this part of the program.

The next level of training is the psychosocial.
These children, youths and young adults are in-
structed in the basic human relationships to the
level of their respective capabilities through en-
gaging in all types of interaction at all levels. This

work is structured through the attendant in ward-
living situations of interaction, through formal
recreational programs, play-therapy programs con-
ducted by the psychology department, and through
arts and crafts.

Psycho-educational training is the next higher
level of training, and it is provided for youngsters
between six and 18 years of age, who are entitled
to an academic education under the American
philosophy of public education. The children and
youths at Woodward get this training at a school
building, just as do children who can stay in their
home communities. The Woodward program is
structured at the trainable and educable levels,
in an educational academic sense, and the young-
sters participate in reading, writing and arithmetic
classes geared to meet their needs and to coin-
cide with their academic ability. In the Depart-
ment of Education and Training, at Woodward,
there are one pre-school teacher, two kindergar-
ten teachers, two primary teachers (one each for
educables and trainables), one intermediate teach-
er for trainables, one teacher for junior high school
trainables, two high school teachers, and one teach-
er each for the blind, for vocal music, for instru-
mental music and for speech therapy. Besides,
there is a recreation staff of three, a habilitation
staff of four, and an arts and crafts staff of seven.
Enrollment in the formal school totals 225; in the
special therapy classes 302; in vocational rehabili-
tation 725; and in recreation 592. Of course these
groups overlap very considerably.

Psycho-vocational training is the next higher
level in the traditional divisions of training. As
a youth reaches his academic plateau and is no
longer profiting academically, it is our belief that
he should be explored vocationally before emo-
tional conflicts arise or trauma occurs. Thus, at 16,
18 or 21 years of age, his innate likes and dislikes
and his vocational preferences and potentials are
inquired into.

THE HABILITATION LADDER

On the basis of these evaluations, a program of
vocational training is then begun. The “habilita-
tion ladder” is as follows:

Rung 5: The fifth rung is the final step in the
patient’s habilitation program, designed to prepare
the patient for placement in the community. He is
taught the skills that he will need if he is to get
along in a community, such as ordering in a res-
taurant, riding an escalator, using street numbers
and addresses, shopping for his own clothing and
many other technics for which he has previously
had no need.

Rung 4: The patients on this rung are the ones
selected to work within the institution in responsi-
ble positions. They are paid $32 per month from
our “Patient Support Fund,” and they live in sepa-
rate quarters, eat at the employees’ home and go
to work as a regular employee does. They are
called “training-patient employees,” and they re-
quire very little supervision. A sub-group on this

376

Journal of Iowa Medical Society

June, 1962

rung consists of the “patient employees.” These
individuals are vocationally oriented for work in
supervised situations, but other factors are not par-
ticularly favorable for outside placement.

Rung 3: This is the “Habilitation Group.” They
are higher-functioning, they have completed their
schooling either by reaching 18 years of age or
by reaching their peak as far as academic training
is concerned. Their ages vary from 18 to 40. From
them, the “Cadre Workers” will be selected. With
proper training and supervision, they will be good
workers, but probably will never be able to func-
tion outside the institution without supervision.
They can be trained to do routine jobs within
the institution, and are given salaries of $16 per
month in addition to room and board. They have
special uniforms, and this type of program gives
them motivation, pride in their work, and prestige.
Their intelligence quotients may be from 30 to 50
or perhaps even higher, but for some reason or
other they are incapable of managing themselves.
This rung is a “sheltered workshop” within the in-
stitution. Assignment to Rung 3 doesn’t necessarily
mean that the patient will always remain there.
He may be moved up to another rung.

We have subdivided the patients on Rung 3 ac-
cording to their attainments socially and vocation-
ally. The sub-groups are: (1) “Cadre Trainees.”
This group is made up of patients showing the
higher degree of social and vocational ability. They
are assigned to our nursing department. We now
have 100 in this group, each receiving the $16 per
month that was mentioned above. They work eight
hours per day, six days per week, and are allowed
a few extra privileges. The cost of this group’s
keep is not charged to the counties. Cadre trainees
live on the same wards, the boys in one area and
the girls in another. (2) “Cadre Workers.” These
are a little less capable than cadre trainees, but are
assigned in all areas of the hospital. We have 600
such boys and girls, and each of them receives a
$1 to $4 canteen card each month. They live in all
sectors of the hospital, and become candidates for
promotion to cadre trainees when the necessary
improvement has been noted. The money for this
group is taken from our Support Fund, which is a
portion of our budget.

Rung 2: This group of patients have been pro-
moted from Rung 1. They will need continued
school training, work training, and planning and
preparation for their climb up the ladder.

Rung 1: These are the low-functional retarded —
the pre-school, kindergarten academic group. Also
on this rung are the spastics, the cripples, and the
mulitply-handicapped retarded who will need spe-
cial training, medical treatment and recreational
planning. There are many of these who will be able
to climb the ladder to varying heights.

THE INSTITUTION AND THE OUTSIDE WORLD

Admissions to and discharges from the institu-
tion can be dealt with appropriately, to be sure,

only in the context provided by the community
environment, with its social processes, attitudes
and resources.

A good pre-admission program eliminates the
waiting list by culling from it the persons who can
be cared for just as well or better elsewhere.

A strong release and after-care program gets
people out of the institution who no longer need
to be there, or who have benefited maximally from
the institution’s program and would be better off
if they were back in their communities.

Since the Code of Iowa places responsibility for
the institutional program for the retarded upon the
Board of Control, at the state level, and upon the
Board of Supervisors, at the county level, we have
developed close relationships with the designates
of each of those bodies. In some counties we think
we have achieved a renewed understanding of
county-state functional responsibility in retarda-
tion problems.

The community consultant has a master’s degree
and some experience in social work, and his func-
tion is primarily that of strengthening, developing
and working with community services. He lives
in the community, is a part of the area that he
serves, and works closely with the counties in
his area, as well as with the Hospital-School.

The major goal is to integrate over-all state
services with the active services in the community
in a way that will best service the retarded person,
his family and the State of Iowa.

The community services program is intended:

a. To strengthen pre-admission, inpatient care
and outpatient services, and generally to enrich
the community program for the mentally retarded
and their families.

b. To stimulate effective cooperation among the
social, educational, medical and lay organizations
within the communities.

c. To promote the development of basic health,
welfare and educational services for the retarded
at the local level.

d. To assist in eliminating duplications of serv-
ices for the retarded.

e. To provide basic casework service, if it is
not already available locally, but only on a tempo-
rary or demonstration basis.

f. To serve as a link between the institution and
the national, state and local Associations for Men-
tally Retarded Children.

g. To assist in related programs of research,
staff-development and in-service training.

CONCLUSION

Until local communities can more adequately
meet the needs of retarded persons, it would seem
that consultants should continue to work and live
in the various parts of the state to encourage the
establishment of outpatient pre-care and after-care
programs, and to serve as liaison between the in-
stitutions and the local workers and officials.

THE JOURNAL Fook Shelf

BOOKS RECEIVED

CLINICAL PATHOLOGY: APPLICATION AND INTERPRE-
TATION, THIRD EDITION, by Benjamin B. Wells, M.D.,
Ph.D. (Philadelphia, W. B. Saunders Company, 1962. $9.00).

A STUDY OF PSYCHOPHYSICAL METHODS FOR RELIEF
OF CHILDBIRTH PAIN, by C. Lee Buxton. M.D. (Phil-
adelphia, W. B. Saunders Company, 1962. $4.75).

SHOCK: PATHOGENESIS AND THERAPY (An Interna-
tional Symposium Sponsored by Ciba, in Stockholm, June
27-30, 1961), ed. by K. D. Bock. (Berlin, Springer-Verlag,
1962. $13.00).

PHYSICAL DIAGNOSIS, SIXTH EDITION, by Ralph H. Ma-
jor, M.D., and Mahlon H. Delp, M.D. (Philadelphia, W. B.
Saunders Company, 1962. $7.50).

THE LOWER DIGESTIVE TRACT (Part ii of Volume III in
the Ciba Collection of Medical Illustrations), prepared by
Frank H. Netter, M.D., edited by Ernst Oppenheimer, M.D.
(Summit, N. J., Ciba Pharmaceuticals Company, 1962.
$15.00).

BOOK REVIEWS

A Textbook of Obstetrics, by Duncan E. Reid, M.D.
(Philadelphia, W. B. Saunders Company, 1962.
$18.50).

With the growing mass of literature that is resulting
from advances in physiology and chemistry, and with
psychosomatic medicine at our door, we need more of
the type of text that Reid and his associates have pre-
pared. The new facts and the old that have to do with
the practice of obstetrics have been correlated and
summarized. This is a text that is especially valuable
for the general man and the student who find either
their time or their experience does not enable them
to read and evaluate even a small amount of the new
work that is being done. The detailed bibliography
will aid those who wish to pursue any one topic more
completely.

This text is surprisingly easy to read, and the au-
thor advocates rational and reasonable procedures.
He emphasizes that what is regarded as true today
may not necessarily be thought true tomorrow. It is
unusual that the reader is not asked to follow the
so-called “dogmas of a center,” but is left free to
think and to use his own judgment on the material
at hand. I think this is one of the strong points of the
book. There is no need for me to enumerate the di-
vision titles and the topics discussed. It is enough to
say that the volume completely covers the field of ob-
stetrics.

As an older man who is getting a little tired, I find
Reid’s book excellent. The wording is simple, concise
and to-the-point. The author hasn’t filled pages when
two sentences would tell the story. The tremendous
effort and life-long dedication that have gone into this
work should be an inspiration to the rest of us in the
profession of medicine. In no other field are basic biol-

ogy and human emotions so interwoven as they are in
reproduction. The obstetrician’s devotion to the saving
of lives is dramatically revealed in this book. May Dr.
Reid’s example serve as an inspiration to the student
and to the practicing physician as they undertake
their work! — J. D. Lutton, M.D.

General Pathology, Third Edition, ed. by Sir Howard
Florey. (Philadelphia, W. B. Saunders Company,
1962. $22.00) .

This book was never intended to be a complete text
on the subject, nor does its editor and authors ap-
proach the diseases by organ systems, as is the usual
practice for the authors of American texts on pathol-
ogy. Rather, this volume is intended to present material
on certain aspects of disease processes. Accordingly,
the chapters bear titles such as “Fever,” “Edema,”
“Thrombosis,” “Healing,” “Influence of Drugs on the
Inflammatory Process” and “Cell and Tissue Reactions
to Viruses.” Each of the 17 British experts has written
on the subject about which he is best informed, and
hence the reader is exposed to the dynamics of disease
processes in what seems to be clear, concise and au-
thoritative language. Oxford lectures served as the
basis for the original text.

A new and, though short, an interesting chapter
has been added in the Third Edition. Its title is “Im-
munology of Tissue Transplants.”

The print is easy to read, and the illustrations are
very good.

Although somewhat expensive, the text might be
of value to the libraries of teaching institutions. —
David Baridon, Jr., M.D.

Problems in Surgery (From Surgical Grand Rounds at
the New York Hospital-Cornell Medical Center) by
Frank Glenn, M.D., ed. by George E. Wantz, Jr.,
M.D. (St. Louis, The C. V. Mosby Company, 1961.
$16.50).

This book contains one year’s selected cases — 152 of
them — in all branches of surgery: pulmonary, cardiac,
vascular, alimentary, liver, biliary tract and spleen,
urologic, neurologic, endocrine, plastic and orthopedic.

Six cases are presented weekly, but duplications
and less-interesting cases are eliminated from the
studies chosen for publication, and the cases are
grouped according to the specialties involved. Cases
are presented with histories, examinations, laboratory
findings and discussions. The discussants are profes-
sors and assistant professors in the various depart-
ments concerned — surgery, medicine, pathology, pe-
diatrics, radiology and anesthesiology — and by distin-

377

378

Journal of Iowa Medical Society

guished visiting professors. The treatment and out-
come are presented, and failures as well as good re-
sults are freely considered. X-rays and pictures are
frequent, the cases have been well chosen to cover
many diverse problems, and the editor has eliminated
superfluous verbiage.

The book is highly recommended for the house staffs
of hospitals, and for study or journal clubs. It dem-
onstrates good examination, workup and thought on
many cases. The methods could be used as models for
local instructional procedures, or the issues raised
could be used as the bases for study and argument.

It is unfortunate that the high costs of publishing
make this volume a luxury item for the private med-
ical library. — Anthony H. Kelly, M.D.

The Monteggia Lesion, by Jose Luis Bado, M.D., trans-
lated by Ignacio V. Ponseti, M.D. (Springfield, Il-
linois, Charles C Thomas, 1962. $6.75) .

Dr. Ponseti and the publishers have done an excel-
lent job in translating and presenting this work by
Dr. Bado in a most interesting manner. Dr. Bado had
studied a group of 55 “Monteggia” lesions treated at the
Institute of Orthopedics and Traumatology in Mon-
tivideo, Uruguay. Sixty per cent of these cases were
examples of the classical “Monteggia” fracture. Fif-
teen per cent represented posterior dislocations of the
upper end of the radius and fracture of the shaft of
the proximal ulna, with posterior angulation. The re-
mainder of the cases were rare injuries of the prox-
imal forearm which Dr. Bado chooses to classify as
“Monteggia” lesions.

The chapters concerning the anatomy, physiology
and etiology of these fractures are most rewarding.
Bado is in agreement with the work of E. M. Evans
published in the journal of bone and joint surgery
concerning the mechanism of injury in the classical
“Monteggia” fracture.

On the subject of treatment, there has always been
a great deal of disagreement. Dr. Bado apparently fol-
lows the teachings of B’oehler and other European
surgeons who favor closed reduction for the “Monteg-
gia” fracture, with the elbow flexed and in forced
supination. This is a more optimistic point of view
than that taught us by Watson-Jones, Speed and Boyd,
and DePalma, who feel that open reduction of at
least the fractured ulna is usually necessary. The au-
thor emphasizes that open reduction of a dislocation
of the head of the radius has never been necessary
in his experience with the classical “Monteggia” lesion.

In “Monteggia” lesions resulting in a posterior dis-
location of the head of the radius and a fracture of
the shaft of the ulna with posterior angulation (the
so-called “flexion” injury of Watson-Jones), Bado fa-
vors closed reduction of the fracture, placing the el-
bow in some flexion unless the injury is compounded,
in which case open reduction is usually employed.
This is the fracture that Watson-Jones feels can be
successfully treated by closed means, using simple ex-
tension of the elbow for reduction and maintenance of
reduction.

This book performs the useful service of emphasiz-
ing that closed reduction of “Monteggia” fractures
is nearly always successful in children, and of point-
ing out that closed reduction is often effective in

June, 1962

adults if the principle of forced supination of the fore-
arm is followed. Several cases in this book emphasize
that when the reduction is less than good, or even
less than excellent, the result will not be acceptable. —
John H. Kelley, M.D.

Fumes Claim More Lives Than
Do Flames

Few of the 12,000 fire victims in the U. S. each
year have actually burned to death; they have
been asphyxiated by toxic combustion gases, ac-
cording to Paul W. Kearney, of West Skohan,
N. Y *

Fire deaths are popularly associated with big
blazes, whereas the “smoky stinker” can be as
deadly as a roaring blaze. Typically, suffocation
is the fate of bed-smokers. About three-fourths of
fire victims die in dwellings, and three-fourths of
that number die upstairs from a fire that started
downstairs, dying in most cases before becoming
aware that there is a fire.

Olsen and his associates at Brooklyn Polytechnic
Institute discovered nearly 30 years ago that the
burning of ordinary household materials generates
from 11 to 14 toxic gases in substantial concen-
trations. Carbon monoxide is always present, but
hydrogen sulfide, ammonia and hydrocyanic acid
gas are as bad or worse than carbon monoxide.
Even though there may not be enough of any of
them, their combination can be fatal.

The vital preventive — aside from periodically
disposing of refuse accumulations and refraining
from smoking in bed — is the planning of a path of
escape other than the stairway, for use in case the
usual exit is cut off, as it often is.

* public health reports, 7 7:248-249, (Mar.) 1962.

W. B. SAUNDERS COMPANY features the fol-
lowing recent books in their full page advertise-
ment appearing on page vii in this issue:

GREEN and RICHMOND— PEDIATRIC DIAG-
NOSIS

A symptomatic approach to diagnosis of child-
hood disorders — telling you what to look for,
how to look for it, and the significance of your
findings.

NEALON— FUNDAMENTAL SKILLS OF SUR-
GERY

Step-by-step procedures in both major and
minor surgery — ranging from management of
infection to closed chest treatment of cardiac
arrest.

THE 1961-1962 MAYO CLINIC VOLUMES
171 valuable articles from this world-famous
medical center on the latest diagnosis and
treatment measures in medicine and surgery.

The Fourteenth Annual AAGP Meeting

REX L. MORGAN, M.D.

The Fourteenth Annual AAGP Scientific Assem-
bly is over now, and it will be recorded as the most
successful of all AAGP meetings to date. The deci-
sion of our national officers to hold the meeting
in Las Vegas was a “calculated gamble” for sev-
eral reasons:

1. Relative inaccessibility, if one considers the
entire country

2. Inadequate housing facilities

3. No national medical meeting had ever been
held there (an AM A interim meeting had been
scheduled there, and then cancelled)

4. The feeling that the public image of the physi-
cian would suffer from holding a national meeting
in a world-renowned gambling center.

The “calculated gamble” was accepted by these
officers with the feeling that the AAGP consists
of serious, responsible physicians who would seek
entertainment in the evening but would attend
the daily meetings. By car, plane and private train,
the doctors flocked to the convention hall in record
numbers. Three weeks before the meeting, all
hotel reservations in the convention city had been
sold — for the first time in AAGP history. The total
registration was slightly less than 8,000, exceeding
the previous high of 7,504, in Philadelphia in 1960.
The sessions were well attended, with the 2,800
seats on the first floor of the auditorium filled by
9:00 a.m. each morning and with an overflow into
the remaining 6,000 balcony seats — a constant
source of wonder to the guest speakers.

The convention hall was extremely impressive,
providing seats for 8,000, and 90,000 square feet
of floor space for exhibits, and being surrounded
by a parking area that would accommodate the
entire car population of Las Vegas.

The scientific lectures and discussions were out-
standing, with 22 of the nation’s renowned authori-
ties covering all phases of practical medicine. The
only disappointment was the absence of Melvin N.
Belli, LL.B., who was to have spoken on “How to
Avoid Malpractice Suits.” Mr. Belli was unable
to come on account of a last-minute plane delay
due to bad weather.

The number of scientific exhibits hit an all-time
high of 153, covering many topics such as strepto-

coccal identification, pinworms, thumb-web con-
tractures, neonatal jaundice, ultrasonics, open
heart surgery, rabies immunization, scalenus anti-
cus syndrome and central causes of sudden death.
In the “new” category, there were exhibits on
environmental radiation, a new treatment for alco-
holism, new skin wound closures without sutures,
and a revelation on excessive height in girls.

The most noteworthy aspects of the meetings, as
far as I was concerned, were sensing the warm,
friendly atmosphere that pervaded the convention
hall, meeting several classmates, making new ac-
quaintances and visiting with our state executive
secretary, Mrs. Isabelle Wandling, who was proud
of the 88 Iowa doctors in attendance — also a new
high. It was a pleasure to meet our state president,
Dr. Verne Schlaser, and later to rejoin him at
the first convocation luncheon for all of the new
physicians who had become active AAGP members
during the past year.

The evening entertainment gave a view of Las
Vegas quite different from the vague feeling of
distrust which many of us had brought with us and
which is probably par as regards a famous gam-
bling resort. The food was good, but the prices were
higher and the service was not so good as I had
found them on a previous visit. The entertainment
was outstanding. Where else could one see “The
Flower Drum Song,” Harry James and the King
Sisters in one evening? Dinah Shore was wonder-
fully relaxed — sitting on a stool singing numbers
requested by members of her audience. The Lido
de Paree, with its beautiful costuming and water-
fall, will long be remembered.

All in all, the Las Vegas meeting was a spectacu-
lar success, and it set a goal for future meetings
to aim at.

Following the Las Vegas meeting, 300 doctors
and their wives went on to Honolulu for a con-

MARK YOUR CALENDAR NOW
SEPTEMBER 12-13, 1962
Fourteenth Annual Scientific Assembly
Iowa Chapter of the AAGP
Hotel Savery
Des Moines

379

380

Journal of Iowa Medical Society

June, 1962

tinuation meeting conducted by Dr. Philip Thorek,
a Chicago surgeon who is an entertaining speaker
and an excellent teacher. As in Las Vegas, the at-
tendance at the breakfast meetings was remark-
able, with over 200 members present for the daily
sessions.

We were extremely well pleased and enthusias-
tic over the Las Vegas and Hawaiian meetings, but
we are increasingly enthusiastic about returning
home, putting into practice what we learned, and
starting to think about the next annual AAGP
scientific assembly, to be held in McCormick Place,
Chicago, in April, 1963.

No Wonder We're Broke!

Here is what the American taxpayer has given,
or lent with little prospect of repayment, since the
end of World War II, not to help win the war, re-
member, but since its end.

And if you think these billions were to win
friends for decency, keep in mind that $57 billions
from a total of $84 billions went to nations that
boast of being “neutral.” They want our money,
but refuse to call themselves our friends or to act
like our friends.

WESTERN EUROPE

Austria $ 1,170,100,000

Belgium-Luxembourg 1,935,200,000

Denmark 822,200,000

France 9,423,600,000

Germany (Federal Republic) 4,993,900,000

Berlin 127,000,000

Iceland 62,600,000

Ireland 146,200,000

Italy (and Trieste) 5,517,000,000

Netherlands 2,416,000,000

Norway 1,024,500,000

Poland 509,400,000

Portugal 370,600,000

Spain 1,470,300,000

Sweden 108,900,000

United Kingdom 8,668,300,000

Yugoslavia 2,132,400,000

Regional 2,237,300,000

FAR EAST

Burma 93,900,000

Cambodia 263,600,000

China (Chiang Kai-Shek) 3,894,500,000

Indochina (undistributed) 1,535,000,000

Indonesia 558,000,000

Japan 3,462,500,000

Korea 4,486,600,000

Laos 301,200,000

Malaya 21,800,000

Philippines 1,555,700,000

Thailand 571,800,000

Vietnam 1,895,900,000

Regional 316,100,000

NEAR EAST

Greece 3,073,500,000

Iran 1,012,500,000

Iraq 65,300,000

Israel 709,100,000

Jordan 230,900,000

Lebanon 86,100,000

Saudi Arabia 46,600,000

Turkey 3,094,900,000

United Arab Republic 295,000,000

Yemen 11,300,000

CENTO 25,200,000

Afghanistan 145,700,000

Ceylon 65,300,000

India 2,383,900,000

Nepal 39,400,000

Pakistan 1,255,700,000

Regional 854,200,000

LATIN AMERICA

Argentina 460,500,000

Bolivia 191,700,000

Brazil 1,376,500,000

Chile 364,600,000

Colombia 249,500,000

Costa Rica 68,700,000

Cuba 52,000,000

Dominican Republic 8,800,000

Ecuador 84,300,000

El Salvador 10,000,000

Guatemala 117,400,000

Haiti 80,400,000

Honduras 34,900,000

Mexico 600,000,000

Nicaragua 42,500,000

Panama 58,600,000

Paraguay 39,500,000

Peru 334,300,000

Uruguay 72,300,000

Venezuela 73,300,000

West Indies Federation 11,500,000

* Overseas Territories 4,800,000

Regional 111,100,000

AFRICA

Ethiopia 115,000,000

Ghana 4,000,000

Guinea 3,800,000

Liberia 73,300,000

Libya 154,000,000

Morocco 194,700,000

Nigeria 6,200,000

Somali Republic 9,100,000

Sudan 44,100,000

Tunisia 135,200,000

*Overseas Territories 60,900,000

Regional 21,600,000

Non-regional 3,336,200,000

TOTAL $84,090,800,000

* “Overseas territories” can be assumed to cover the re-
maining colonies of European countries.

The source of these figures is the congressional record.

1962-1963 Officers

Our state president, Miss Margaret Hansen, was
born and educated in Davenport. She graduated
from Immaculate Conception Academy and attend-
ed the Women’s Division of St. Ambrose College.
She was employed for five years as receptionist,
bookkeeper and secretary by Mercy Hospital; for
seven years she worked in the office of a Davenport
finance company; and prior to 1954, when she
began her present employment with Dr. W. Hol-
lander, a Davenport psychiatrist, she was a staff
member of the Davenport Psychiatric Hospital.
She has served the Scott County Association of
Medical Assistants for two years as president, and
has also served as its secretary and as the chairman
of its Finance Committee. She is a charter member
of the Davenport chapter.

Our state vice-president, Mrs. Gladys Knight, is
a native of Omaha. She is a high school graduate,
and has taken general business courses. At present
she is employed by Dr. C. W. Seibert, of Waterloo.
Her past employment includes four years as secre-
tary-assistant for an Omaha ear, nose and throat
specialist, two years as assistant bookkeeper at

IAMA President

Miss Margaret Hansen

Doctors’ Hospital, Omaha, and nine months as sec-
retary to Drs. F. H. Entz and R. F. Kruse, of Water-
loo. She has served the Black Hawk County Med-
ical Assistants as president, and the state organiza-
tion as corresponding secretary.

The state president-elect, Mrs. Marjorie Snyder,
is from Anamosa. She is a member of the Linn
County Association of Medical Assistants, and has
served it as vice-president and as president. She
has served the State Association as corresponding
secretary, editor of the annual bulletin, and con-
vention program chairman for 1962. She received
her training as a technician from the Northwest
Institute of Medical Technology. For the past eight
years she has been employed by Drs. J. D. Paul,
G. F. Brown and J. L. Bailey, in Anamosa. She has
also worked as a technician at Mercy Hospital, Des
Moines, and in Dodge City, Kansas.

The state recording secretary, Mrs. Dolores Mal-
linger, is employed by Dr. E. M. Swanson, a Ft.
Dodge ophthalmologist. Her previous employers
were the late Drs. A. S. McMillen and L. L. Leigh-
ton, also of Ft. Dodge. She is a native of Vincent,
Iowa, and received her education in the Ft. Dodge
Public Schools and graduated from the Tobin Busi-
ness College. She is a charter member of the Ft.
Dodge chapter of Medical Assistants, and has
served it as secretary, president-elect and presi-
dent. She was the 1962 publicity chairman of
IAMA.

The state treasurer is Mrs. Isabelle Kirtley, a
graduate of East Des Moines High School. For five
years, she was employed as secretary to a former
Capital City Commercial College instructor, Mr.

G. B. Frost. Thereafter she worked in the same
office for 33 years — from 1928 to 1934 with Dr.

H. C. Schmitz; from 1934 to 1953 with Dr. B. F.
Kilgore and Dr. Schmitz; and since the latter’s
death in 1953, with Dr. Kilgore. She has been a
member of the Des Moines chapter of Medical
Assistants for five years, serving as its treasurer,
social chairman, publicity chairman and member
of its Program Committee.

Past-president Miss Waneta Christensen remains
on the Executive Committee of the state organiza-
tion this year, and will serve as liaison with Abbott
Laboratories for a tour of that firm’s facilities at
Chicago in 1963. She is a registered x-ray techni-
cian employed by Drs. M. M. Wicklund, R. W.
Blanchard and O. K. Lanich, in Waterloo.

Miss Helen Hughes, a past-president of IAMA
and the Iowa City District, was appointed state
parliamentarian. She is employed by Dr. Philip
McLaughlin, of Coralville.

381

382

Journal of Iowa Medical Society

June, 1962

Mrs. Grace Brock, of Panora, was appointed
state historian, a post that she is occupying for the
eighth year. She is employed by Drs. C. A. Nicoll
and R. J. Peterson, of Panora, and is a member of
the Des Moines chapter of IAMA.

Mrs. Jeanne Green, of Davenport, was appointed
corresponding secretary. She is a charter member
of the Scott County Association, and has served
as its president and as co-chairman of its commit-
tee for the 1961 IAMA convention, which was held
in Davenport. She is employed by Dr. James
Bishop.

The delegates to the 1962 convention of the
American Association of Medical Assistants, to be
held in Detroit in September, are Misses Margaret
Hansen and Margaret Burnside, and Mrs. Mar-
jorie Snyder. The alternate delegates are Miss
Waneta Christensen and Mesdames Gladys Knight
and Dolores Mallinger.

1962 COMPONENT SOCIETY PRESIDENTS

Black Hawk Association — Mrs. Sue Phillips,
c/o Dr. T. L. Trunnell, 616 Black Building, Water-
loo

Des Moines Chapter — Miss Nancy Hutson, c/o
Dr. M. Dubansky, 1055 Fifth Avenue, Des Moines
14

Des Moines County — Mrs. Roberta Beardsley,
c/o Dr. Walter C. Friday, Farmers and Merchants
National Bank Building, Burlington

Ft. Dodge District — Miss Ardyce Swanson, c/o
Dr. Dan S. Egbert, Carver Building, Ft. Dodge

Iowa City District — Miss Gertrude Paulus, c/o
Medical Associates, 227 N. Dubuque Street, Iowa
City

Jasper-Poweshiek Association — Miss Guylette
Morse, c/o Drs. Billingsley, Wright, Ferguson and
Moles, 321 E. Third Street North, Newton

Lakes Area — Mrs. Sally Nelson, c/o Dr. Denes S.
Far ago, Arnolds Park

Linn County Association — Mrs. Alyce Redel, c/o
Drs. Wolverton and Sedlacek, 1953 First Avenue
S.E., Cedar Rapids

Mason City Association — Mrs. Florence Wagner,
c/o Dr. A. J. R. Stueland, Medical Arts Center,
Mason City

Oskaloosa District Association — Mrs. Modell
Newport, c/o Drs. Collison and Smith, 1225 C Ave-
nue East, Oskaloosa

Scott County Association — Mrs. Marlene Mitch-
ell, c/o Dr. A. W. Boone, 528 Davenport Bank
Building, Davenport

Wapello County Association — Miss Mary Kay
Evitts, c/o Drs. Emanuel, Ebinger and Wetrick,
203 East Second Street, Ottumwa

Woodbury County Association — Mrs. Marian
Clayton, c/o Drs. Harrington, Wagner and Horsley,
401 Davidson Building, Sioux City.

The Doctors' 'Revolt'

In a speech the other day, Labor Secretary Gold-
berg pleaded for “more light and less heat” on the
subject of medical care for the aged.

Well, we certainly second Mr. Goldberg’s plea,
and we only wish some of his associates would
heed it. For a great deal of heat — and very little
light — is being supplied by advocates of the Ad-
ministration plan to provide medical care for the
elderly through Social Security.

No one knows how many of the aged actually
need financial help with their medical bills. And
yet to hear Administration officials talk, you might
think they were equipped with precise data, not
only on the present problem but on all its future
aspects.

Private insurance programs for the elderly are
multiplying rapidly, and by 1970 about 90 per cent
of the people over 65 are expected to be covered
by private plans. But Government spokesmen
claim they already can see that the private ap-
proach is “clearly inadequate.”

A Federal-state medical care program is just
getting under way, but Health, Education and
Welfare Secretary Ribicoff already has pro-
nounced it a dismal failure.

The only way to attack this unknown problem,
the Administration would have us believe, is to
provide limited hospital care to everyone covered
by Social Security, whether they need financial
help or not. And anyone who says this isn’t so, the
Government officials suggest, must be opposed to
providing adequate medical care for our older cit-
izens. In fact, the Democratic National Chairman
said not long ago, critics of the Administration
plan cause the public to believe they are allied
with the John Birch Society.

In this climate of innuendo and invective, it’s
surely understandable that some of the opponents
of the Administration proposal are issuing strong
statements of their own. A number of doctors in
New Jersey and some other states have declared
they won’t have anything to do with a Social Se-
curity medical plan, though they have stressed
that they will continue to provide free medical care
to the needy.

This has brought threats of punitive laws and
cries that the doctors are violating their Hippo-
cratic Oath. But what it really means is that a
number of doctors are demonstrating their con-
cern about the dangers of a compulsory medical
plan.

The spokesmen for the Administration are doing
little to erase that concern. Only by calm, careful
analysis can we ever decide just how big the prob-
lem is and, then, what to do about it.

THE WALL STREET JOURNAL,

Tuesday, May 8, 1962

RIGHT NOW— A Grave Danger is
Confronting Each of Us—

Here Are The FACTS About The Two "Over 65" Heolth Care Programs

VOLUNTARY

(Kerr-M ills Law — already enacted and ready to go
to work)

COMPULSORY

(King-Anderson Bill — supported by the Administra-
tion— a form of socialized medicine)

WHO IS

Any person over 65 who needs help, regardless of So-
cial Security eligibility. It permits COMPLETE financ-
ing of health care — especially for those with serious,
long-term illnesses.

COVERED?

Only those eligible for Social Security benefits. Pay-
ment would be essentially for hospital and nursing-home
care, with patient paying $10 per day for first nine days
in the hospital.

HOW IS ELIGIBILITY DECIDED?

Tax dollars will be conserved, and overuse of the pro-
gram will be discouraged through regular financial and
medical evaluation of patients’ needs at the local level.

Everyone eligible for Social Security benefits would be
subsidized, regardless of need. Lack of local control
would encourage overuse and abuse of the program.

WHAT IS

On a federal-state matching formula, 42c of each dollar
will come from state taxes and 58c from general federal
revenue. These funds will finance care for those who
actually need help — not the many elderly people who
are willing and able to pay their own bills.

WHO CONTROLS

Kerr-Mills is self-restricting in that it finances care on a
need basis. Moreover, Iowa lawmakers will maintain
close surveillance, since the state must appropriate
matching funds each year. Thus, Iowa can tailor its
plan to meet the needs of its elderly citizens — and ad-
minister it in the best interests of Iowa citizens.

WHICH PL/

Before any alternative is considered, the Kerr-Mills Act
should be given an opportunity to work, for it is far
superior to any other proposal that has been offered thus
far. An enabling act has been passed in Iowa, and funds
should be appropriated to put it into effect. It creates
an opportunity for complete understanding and coopera-
tion by all parties involved in health care — govern-
mental, hospital and medical — AT THE PLACE
WHERE UNDERSTANDING COUNTS MOST: AT
THE LOCAL LEVEL!

HE COST?

The Social Security tax would be raised V4 of 1% for
employees and employers alike and % of 1% for the
self-employed — and the tax base would be raised from
$4,800 to $5,200. Even without the King-Anderson Bill,
the Social Security tax is scheduled to reach 9% of
the first $4,800 of income by 1969.

THE PROGRAM?

King-Anderson — if enacted — would be controlled from
Washington, D. C. Because of politics, both coverage
and costs would constantly increase. Its proponents
have already said that their ultimate objective is medical
care for everyone in the country — regardless of age —
under Social Security.

N IS BEST?

The King-Anderson Bill is based on the false assumption
that only federal legislation can solve the sociological
problems of older people. Rather, the federal government
should enter the picture only after the individual, his
family, his community and bis state have shown that
they can’t meet an individual need. The King-Anderson
Bill — if enacted — would lower the quality of medical
care, for government regulations would increase, hospital
facilities would be overused and time-honored doctor-
patient relations would be disrupted.

This proposal strikes at the very foundations of our
Democracy!

EXPRESS YOUR OPINION TO OUR NATION S LAWMAKERS!

D A

Iowa Congressional Districts

First Congressional District— Fred Schwengel (R), Davenport (Scott)

Second Congressional District— James E. Bromwell (R), Cedar Rapids (Linn)
Third Congressional District— H. R. Gross (R), Waterloo (Black Hawk)

Fourth Congressional District— John Kyi (R), Bloomfield (Davis)

Fifth Congressional District— Neal E. Smith (D), R.F.D., Altoona (Polk)

Sixth Congressional District— Merwin Coad (D), Boone (Boone)

Seventh Congressional District— Ben F. Jensen (R), Exira (Audubon)

Eighth Congressional District— Charles B. Hoeven (R), Alton (Sioux)

U. S. SENATORS FROM IOWA

Bourke B. Hickenlooper (R) Cedar Rapids

Jack Miller (R) Sioux City

You may wish to address your letter to Congressman Wilbur Mills, chairman
of the Ways and Means Committee of the U. S. House of Representatives, and to
send the original to him, and copies to both Iowa senators and to the representa-
tive from your congressional district.

Letters to congressmen should he addressed to the House Office Building,
Washington 25, D. C., and letters to senators should be addressed to the Senate
Office Building, Washington 25, D. C.

THE DOCTOR'S BUSINESS

Hedging Against Economic
Fluctuations

HOWARD D. BAKER
Waterloo

How can one build up his investment portfolio
so as to provide maximum protection against in-
creases and decreases in the value of the dollar?

A combination of two types of investments or
contracts will accomplish that goal: fixed-dollar
contracts (such things as savings accounts and
mortgages having specified or fixed redemption
values), and flexible or equity contracts (such
things as corporate stocks or real estate having
flexible values dependent upon current market
prices).

Flexible contracts serve as an inflation hedge, for
if prices increase and the purchasing power of the
dollar decreases, the market prices of these hold-
ings will rise. The fixed-dollar contracts serve as
a hedge against price declines and deflation, for
as the purchasing power of the dollar increases and
prices go down, the value of these properties will
rise.

By maintaining one’s investment portfolio ap-
proximately at a 50-50 balance, the increased value
of one type of contract will offset the decrease in
value of the other, thereby maintaining the over-all
purchasing power of the plan.

The consensus is that this plan should be fol-
lowed as one sets up a retirement plan. When the
basic plan has been completed and additional funds
become available for investment, the hedging fea-
ture can be abandoned, but the original portfolio
should always be kept in balance.

Cash values of life insurance and the discounted
value of accounts receivable (both of which are
fixed-dollar properties) should be considered as
one determines and maintains the balance between
fixed and flexible contracts.

This plan should not be regarded as a perfect
hedge, since the market situation of one investment
can vary more than another, but the plan is basi-
cally sound and is generally accepted as the most
suitable economic hedge that can be devised.

A simple example of this plan in operation
would consist of $1,000 in savings and loan depos-
its and $1,000 in good grade common stocks. If a
50 per cent inflation were to occur, the purchasing
power of the savings and loan account would be
reduced to $500, but the purchasing power of the
common stocks would rise to $1,500, resulting in
the same total purchasing power as before. If, on
the other hand, a 50 per cent deflation were to
occur, the common stocks would be worth only
$500, but the purchasing power of the savings and
loan account would have risen to $1,500, in terms
of the dollars originally deposited. Assuming that
market fluctuations were exactly equal on all
goods, there would be no loss of purchasing power
in either inflation or deflation.

Middle States Branch, American
Public Health Association

The meeting of the Middle States Branch of the
American Public Health Association, at the Radis-
son Hotel in Minneapolis on June 6-8, has been
designated the Walter L. Bierring Memorial Pro-
gram. Dr. Bierring, who died last summer at the
age of 92, was organizer and first president of the
Middle States Branch of APHA. Dr. Leonard W.
Larson, president of the AMA, is to deliver the
principal address.

Dr. James F. Speers, director of the Des Moines-
Polk County Health Department, is scheduled to
report on the newly-established Des Moines home-
maker service, and Mr. Howard Benshoof, for-
merly head of the vocational rehabilitation division
of the Iowa Department of Public Instruction, and
now a regional representative for such activities
working out of the USPHS office in Kansas City,
is to have a part in one of the panel discussions.
The Iowans among the officers of the Middle States
Branch are Mattie Brass, R.N., and Thelma Luther,
R.N., vice-president and secretary-treasurer, re-
spectively. Both are in the Public Health Nursing
Division of the Iowa Department of Health.

383

STATE DEPARTMENT OF HEALTH

COMMISSIONER

Erythema Infectiosum

Each spi'ing since 1957 our attention has been
called to communities faced with a mild type of
illness somewhat similar to measles. Usually the
problem is in the school. The questions most fre-
quently asked about it are:

1. If this isn’t measles and since the children
aren’t really ill, should they be kept from school?

2. If they return to school, should they be sent
home every time the rash blossoms out again?

3. If there is a period of exclusion from school,
how long should it be?

The onset of illness is marked by a rosy erythe-
ma over the cheeks and chin. It extends laterally
from the nose to form a butterfly pattern over the
cheeks. An appearance of circum-oral pallor is
produced. The majority of cases occur in children
below 10 years of age, the greater number being
in youngsters of the six to nine year age group.
The typical case, then, is a six- or seven-year-old
youngster who may not feel ill at any time during
the course of the disease. At the time the rash
appears over his cheeks, he may state that his skin
has felt itchy for several days. Almost all of the
patients at Way land (56 cases in a school enroll-
ment of 330) reported an intense itching during
the early appearances of the rash. A few young-
sters will complain of chilliness, of sleepiness or of
tiring easily. The throat, when the rash is develop-
ing, will show some reddening around the fauces.
The tongue may be magenta in color. Positive lab-
oratory findings are limited to a moderate eosino-
philia in two or three per cent of the cases. In
Iowa, this was noted particularly in the older pa-
tients at Parkersburg.

The rash appears on the body a day or two after
making its first appearance on the face. It appears
on the forearms, shoulders, throat, lower thighs
and legs, and it leaves an erythematous lacework
appearance with some faint cyanotic coloring. The
later rash stages are marked by periods of tempo-
rary recurrence. These may be brought on by exer-
cise, warm baths or even exposure to sunshine.
Anything occasioning a sudden temperature change
may cause the rash to return. The interval from
the earliest appearance of the erythema about the
face to the last appearance or recurrence of the
rash over the body may vary from seven to 10
or even 14 days.

The great majority of cases diagnosed are in

persons under 20 years of age. Of the 58 cases
studied at the Way land School in Henry County,
the oldest was 20. In that instance we terminated
our studies as the wave of infection was rapidly
dwindling in the school. It may be that if we had
returned later, we might have found secondary or
tertiary cases in older age groups among the fam-
ily members. This was the situation at Parkers-
burg, in Butler County. Our study there was begun
late. Most of the cases seen were parents of chil-
dren who had had the illness previously. This
older age group ranged from 25 to 54 years of age.
Most of those patients complained of soreness and
swelling of the wrists, hands, fingers and feet.
Some had one or two degrees of fever.

The Parkersburg outbreak, in 1957, was the first
to be called to our attention. The second was the
Wayland outbreak, in 1959, and it was closely fol-
lowed by a similar episode in neighboring Wash-
ington. We were informed that same year that the
infection was also present in Marion and Mahaska
Counties, in the same area of the state. In 1960 it
appeared in several north-central counties. Thus
far in 1962, we have had reports from four coun-
ties. The first of them was of the illness in the Dow
City-Arion Community School, in Crawford Coun-
ey. We have started an intensive study of the 78
cases there, in a school enrollment of 485. The
Donnellson Elementary School, in Lee County, has
reported 50 cases. Onawa, in Monona County, has
reported 40 cases, and a few cases have appeared
in one of the schools at Iowa City, in Johnson
County.

Although reports in the literature state that the
infection may occur either in the spring or fall,
all of our Iowa outbreaks mentioned above have
occurred in the late winter or early spring.

This disease, Erythema infectiosum, is primarily
a problem in diagnosis. Once the condition has
been identified, the problem as it faces a commu-
nity school is automatically taken care of. Since
we know that the disease is seldom more severe
than an ordinary common cold, there is no need
for keeping the child away from school. Once the
school has been given that information, it can
return to the “even tenor of its way.”

From a strictly public health standpoint, we are
further interested in obtaining materials for virus
study from certain of these outbreaks. We are cer-
tain that the disease is caused by a virus, but
to date there still is some doubt that the true virus

384

Vol. LII, No. 6

Journal of Iowa Medical Society

385

of the infection has actually been isolated. For this
reason, we are using one of the outbreaks as an
area from which to gather a large number of speci-
mens for virus study at the Regional U. S. Pub-
lic Health Service Communicable Disease Center
Laboratories in Kansas City.

REFERENCES

1. Wadlington, W. B.: Erythema infectiosum: report of
epidemic. J. Tennessee M.A., 50:1-5, (Jan.) 1957.

2. Condon, F. J.: Erythema infectiosum — report of area-wide
outbreak. Am. J. Public Health, 49:528-535, (Apr.) 1959.

Elderly Patients Make Errors in
Medication

Elderly, chronically ill patients are likely to
make errors in following directions for taking
medication, according to Doris R. Schwartz, as-
sistant professor of outpatient nursing, Cornell
University-New York Hospital School of Nursing,
et al.* They reported that 179 of their institution’s
outpatients made 269 such mistakes. Multiple mis-
: takes were the more common, but most of them
were not serious.

Patients made potentially serious errors of
omission, took medicine not prescribed by their
doctors or in the wrong dosage, erred in sequence
or timing, or were confused or had inaccurate
knowledge about the purpose of the medications.

Surprisingly, the oldest patients were not the
most likely to make errors, although those 75
years old and older made more errors than
younger patients. Sex apparently had no bearing
on proneness to medication errors. Widowed, di-
vorced or separated persons made more errors
than those who were single or married, and the
proportion of errors was larger among persons
who lived alone than among those who lived with
one or more other persons.

An unexpectedly large proportion — 52 per cent
— of patients with high school or higher educa-
tion made errors in taking medication.

Blindness had less to do with errors than might
have been expected. Patients with a large number
of secondary diagnoses made more errors than
those with few such diagnoses.

Determination of the capacity of each patient
to take responsibility for his own medication is of
the utmost importance in planning a program of
self-administration of drugs by elderly patients,
the authors said. They suggested that many errors
could be prevented by specific instructions on
labels, regular examination of home medication
procedures, instructing patients after prescriptions
have been filled, instead of giving instructions on
pieces of paper, all of which present an identical
appearance, use of visual aids, requiring new pa-
tients to bring in all drugs prescribed for previous
I illnesses or currently being taken, and employing
the public health nurse in clinical planning of
medication schedules.

* public health reports, 77:227-228, (Mar.) 1962.

Morbidity Report for Month of
April, 1962

Disease

1962

Apr.

1962

Mar.

1961

Apr.

Most Cases Reported
From These Counties

Diphtheria

Scarlet fever

348

500

299

Jefferson, Johnson, Kos-

Typhoid fever

suth, Polk, Scott

Smallpox

Measles

2855

2960

1345

Entire state

Whooping cough

Grundy, Jackson

Brucellosis

Polk

Chickenpox

278

315

901

Dubuque, Page, Polk, Pot-

Meningococcic

meningitis

tawattamie, Shelby,
Story

Webster

Mumps

359

304

850

C’ay, Des Moines, Mont-

Poliomyelitis

gomery, Pottawattamie

Infectious

hepatitis

115

369

Polk, Pottawattamie,

Rabies in animals

Scott, Wayne,
Woodbury

Carroll, Clinton, Hardin,

Malaria

Muscatine, O'Brien,
Poweshiek, Washington

Psittacosis

Q fever

Tuberculosis

For the state

Syphilis

101

1 1 1

For the state

Gonorrhea

146

For the state

Histoplasmosis

Appanoose, Floyd, Lee

Food intoxication

Meningitis (type
unspecified )

Diphtheria carrier

Aseptic meningitis

Salmonellosis

Boone

Tetanus

Chancroid

Encephalitis (type
unspecified )

H. influenzal
meningitis

Amebiasis

Boone

Shigellosis

Influenza

508

©AllMloM CJ

ew6

■6

The Auxiliary's New President

Mrs. Arthur C. Richmond, of Ft. Madison, the
newly-installed president of the Woman’s Auxili-
ary to the Iowa Medical Society, has served as
president of the North Lee County Woman’s Auxil-
iary and as first vice-president of the State Auxili-
ary for six months, and then, upon the resignation
of the president-elect, Mrs. E. B. Dawson, she was
chosen to succeed Mrs. B. F. Kilgore as president.

Mrs. Richmond’s husband, Dr. Richmond, is an
eye, ear, nose and throat specialist who has prac-
ticed at Ft. Madison since 1936. Sue graduated
from St. Luke’s Hospital School of Nursing, Den-
ver, Colorado. The Richmonds have two children:
a son who graduated from S.U.I. in 1960, is now in
the U. S. Army at Ft. Leonard Wood, and plans to
enter the College of Medicine at S.U.I. next fall,
and a daughter who is a senior this year at S.U.I.,
majoring in mathematics.

Sue Richmond has two interesting hobbies. She
collects cut glass and loves to play bridge. She is
a member of the Episcopal Church and partici-
pates in the work in its various areas. In addition

to the Auxiliary, she is active in P.E.O., D.A.R.,
the Sacred Heart Hospital Guild, and the Rebecca
Pollard Study Club.

Tips for Safety

RECREATION SAFETY— PLAYGROUNDS AND G'/MS

(About one-fifth of all student accidents during
the school year happen on school grounds)

1. Have a supervisor in attendance at all times!
when grounds and gym facilities are being used.

2. Provide sufficient space for all sports played.:

3. Inspect play areas and equipment daily for:
breakage, broken glass, sticks, wire and sharp
stones.

4. Limit each child’s participation in sports to
his age or capabilities.

5. Maintain close teacher supervision to ensure
safe and proper use of all sports equipment.

6. Use approved playground surface — e.g. tor-|
pedo sand, gravel, loam, tanbark, limestone screen-!
ing, grass.

7. Make sure youngsters wear suitable clothing
and have proper equipment for specific sports.

8. Store all portable equipment when not in use.

9. Mark off areas for swings, slides and hand
bars with white safety lines.

10. Keep first aid equipment on hand at all
times.

TRAFFIC SAFETY— CAR MAINTENANCE

1. Have a garage check made on your car at
least once a year — oftener, if it’s an older model.

2. Keep dashboard and rear seat shelf clear of
sharp and heavy objects.

3. Eliminate eye-distracting objects like baby
shoes suspended from the rear vision mirror.

4. Make routine car safety check about once a
month to make sure that battery, radiator, horn,
windshield wiper, rearview mirror, steering wheel,
rear red light, numberplate light, directional sig-
nals, tires, hand brake, foot brake, exhaust system,
oil gauge and headlights are in good operating con-
dition.

5. Have cooling system flushed and anti-freeze
put in before freezing weather arrives.

6. Carry complete supplies for an emergency

386

Vol. LII, No. 6

Journal of Iowa Medical Society

387

tire change. Be sure the jack is in good condition.

7. Check muffler and exhaust system periodically
to eliminate the hazards of carbon monoxide
poisoning.

8. Always carry tire chains, sand and a shovel
for winter driving.

9. Be sure heater-defroster is operating properly
in winter to avoid interior windshield fogging.

10. Protect your own life and the lives of your
passengers by installing seat belts. About half of
the 1960 traffic fatalities (nearly 40,000) would
have been avoided if seat belts had been used.

Volunteer Health Service Award
Winner

Patricia Seely Jacobsen (Mrs. Harold E.), Sioux
City, was named the outstanding Volunteer Health
Service Award Winner for 1962 at the Annual
Meeting of the Woman’s Auxiliary. Her name was
presented by the Woodbury Sioux Med Dames
and the Woodbury County Medical Society.

Mrs. Jacobsen, cited for the depth and diversifi-
cation of her volunteer service, has concentrated
her efforts on the activities of the Siouxland Re-
habilitation Center. She has been active in that or-
ganization since its inception. As a volunteer work-
er, she was active for nine years in its nursery
school, conducted tours, and in an effort to secure
financial support has served in public relations
and organizational liaison capacities.

In addition, Mrs. Jacobsen was elected to the
Board of the Woodbury County Crippled Children
and Adults Society. In 1959 and 1960 she served as
president of that organization, compiling a board
manual during her tenure, which served as a
model for those of other centers, and she super-
vised a revision of the bylaws. Also during her
term of office a $119,000 addition was financed and
constructed, including a hydrotherapy wing and
department, occupational therapy facilities, and an
underground tunnel that connects the Center with
the adjacent Methodist Hospital, to facilitate pa-
tient transportation. In 1961, Mrs. Jacobsen was
the Iowa delegate to the World Congress of Crip-
pled Children and Adults in New York, and is
currently active on the board in charge of volun-
teers.

Mrs. Jacobsen’s diversified volunteer work in the
fields of health and health education has centered
on work with young people. Following the nation’s
worst polio epidemic, she trouped her original
puppet show through the pediatric departments of
Sioux City hospitals. Under the auspices of the
Junior League, she has been active in arts-and-
crafts and personal-grooming programs at St. An-
thony’s Home for Children, the Boys’ and Girls’
Home, and the Florence Crittenden, and St. Mon-
ica’s Homes for Unwed Mothers.

She has been active in P.T.A. and Scouting

Mrs. Harold E. Jacobsen, Sioux City

through her close relationship with her children,
serving in various offices as well as girl scout
leader of her daughter Holly’s troop and den
mother for her son Alex’s troop.

Mrs. Jacobsen is an active member of Trinity
Lutheran Church, is a regular Sunday School
teacher, and has served as vacation Bible-school
superintendent. She has been extremely active in
the Junior League in Sioux City, both in adminis-
tration and in community programs. She is an
active member of the Board of Managers, chairing
the current Project Finding Committee.

Mrs. Jacobsen studied art at the University of
Minnesota, did art work for Dayton’s University
Store, in Minneapolis, and now uses her artistic
skills in connection with her many community ac-
tivities in Sioux City. She recently created the
space puppet that played the title role in “Whizzle,”
a Junior League science fair television series, and
was active in the League’s current Book Band-
wagon TV program at its inception.

Mrs. Jacobsen has been an active participant in
total community programs too numerous to be in-
corporated in this particular account, but with all
these activities the Jacobsens are a very closely-
knit family unit. Mr. Harold E. Jacobsen, treasurer
of Albertson & Company, is the president-elect of
the Iowa Heart Association. Mother Patty, father
Harold, daughter Holly, and sons Alex and Andy
enjoy many family activities, including boating,
swimming, ice skating and other outdoor sports.
Mrs. Jacobsen gives unselfishly of her time and
talents with the blessing and assistance of her
family.

388

Journal of Iowa Medical Society

June, 1962

National Auxiliary Convention
Chicago, June 25-28

The National Auxiliary Convention will be held
in Chicago, Illinois, June 25-28, 1962, with head-
quarters at the Pick-Congress Hotel, on Michigan
Avenue.

Each day of the convention is to be divided in
three sections:

(1) An 8:30-9:30 Open Meeting — which will
seek to attract all doctors’ wives, be they Auxiliary
members or the most vaguely interested potential
members: Speakers of national fame, subjects im-
portant to each doctor and his wife, and coffee
will be headlined.

(2) Business Meeting

(3) “The Auxiliary at Work”

Every physician’s wife is invited and urged to
attend each session, but this subdividing will help
the convention-goer whose time for attendance at
Auxiliary sessions is limited. This division will en-
able her to select more easily the presentations
that she will find most meaningful.

All official delegates will be expected to attend
all sessions pertaining to business and program-
ming. There will be no afternoon meeting on
Wednesday, and there will be no Friday meetings.

There are several social activities planned, in-
cluding teas and luncheons. There is to be a Small
Fry and Teen-age Convention Program under the
auspices of the Woman’s Auxiliary to the Amer-
ican Medical Association — minimum age, five
years. This includes tours of the city, with stops
at points of interest; a ball game; a visit to the
Riverview Amusement Park; a swimming party at
Hotel Sheraton-Chicago; a boat excursion; and a
special night club tour for students. Young people
participating in this program should register as
early as possible and should secure tickets and
badges.

Sn Memoriam

Henceforth there is laid up for me a crown of
righteousness, which the Lord, the righteous fudge,
shall give me at that day. — II Timothy 4: 8
Mrs. Ralph Selman, Ottumwa
Mrs. Peter W. Beckman, Perry

National Auxiliary Art Exhibit

Pick-Congress Hotel — Shelby Carter Rooms
1 962 Convention

An Art Exhibit is being sponsored by the Wom-
an’s Auxiliary to the AMA during the 1962 Con-
vention. If you will refer to the entry regulations
for your entry in the Art Exhibit at the Iowa An-
nual Meeting you will be able to determine the
types of entries acceptable, since the classifications
are identical. The rules are also the same, with the
exception that entries will be received from June
18 to 22 and should be labelled as follows for
shipping: Woman’s Auxiliary to the American

Medical Association, Pick-Congress Hotel, 500 S.
Michigan Avenue, Chicago 5, Illinois. Attention:
Miss Margaret Wolfe, “ART EXHIBIT.”

Be sure to show “ART EXHIBIT” on mailing
sticker, so package will receive special handling.

All entrants please note: “While every care will
be given all entries during handling, storage and
showing, entrants will be asked to release the
Woman’s Auxiliary, the AMA and the Pick-Con-
gress Hotel from liability on loss by fire, theft or
damage.”

One more item to which we wish to direct your
attention is that entrants are requested to arrange
for the return of their work/or works after the
close of the Exhibit, which will be 5:00 Wednes-
day, June 27, with no extension of time. All pack-
ing and shipping charges are to be borne by the en-
trants, since the Woman’s Auxiliary and the Pick-
Congress Hotel accept no responsibility for this
service.

Information about the work to be shown should
be sent to: Mrs. Silvio DelChicca, chairman, Con-
vention Art Exhibit, 2600 N. Lakeview Avenue,
Chicago 14, Illinois.

AMEF Note Paper and Envelopes
$1.00 per pack of 10 each
Order from
Woman's Auxiliary
529-36th Street
Des Moines 12, Iowa

Proceeds will be donated to the American
Medical Education Foundation

WOMAN'S AUXILIARY TO THE IOWA MEDICAL SOCIETY

President — Mrs. A. C. Richmond, 1132 Aven Avenue, Fort
Madison

President-Elect— Mrs. G. J. McMillan, 436 Avenue C, Fort
Madison

Recording Secretary — Mrs. M. A. Schacht, 1025 North 23rd
Street, Fort Dodge

Corresponding Secretary — Mrs. F. L. Poepsel, Box 176, West
Point

Treasurer — Mrs. M. B. Cunningham, Norwalk

a look at the
literature

240285

IOWA MEDICAL SOCIETY

U.C. MEDICAL CENTER LIBRARY

JUL 19 1962

San Francisco, 22

Treatment results were good, and in
many cases a dramatic response was noted.
Many of the cases had previously failed to
respond to various types of therapy, includ-
ing, in some instances, other topical corti-
costeroid preparations.^^

— Gray, H. R., Wolf, R. L., and Doneff, R. H.: Evaluation of Fluran-
drenolone, a New Topical Corticosteroid, Arch. Dermat., 8d: 18, 1961.

Description: Each Gm. Cordran cream and ointment contains 0.5
mg. Cordran. Each Gm. Cordran™-N cream and ointment con-
tains 0.5 mg. Cordran and 5 mg. neomycin sulfate.

All forms are supplied in 7.5 and 15-Gm. tubes.

Cordranm-N ( Jlurandrenolone with neomycin sulfate , Lilly)

This is a reminder advertisement. For adequate information for use , please
consult manufacturer’s literature. Eli Lilly and Company , Indianapolis 6,

Indiana.

Sfieey

The incidence of postoperative wound infections, particularly among debilitated patients, pre-
sents a serious hospital problem.1 These infections are caused in many cases by strains of staph-
ylococci resistant to most antibiotics in common use.1'2-3 In such instances, CHLOROMYCETIN
should be considered, since “...the very great majority of the so-called resistant staphylococci
are susceptible to its action.”4

Staphylococcal resistance to CHLOROMYCETIN remains surprisingly infrequent, despite wide-
spread use of the drug.2'4-5'7 In one hospital, for example, even though consumption of
CHLOROMYCETIN increased markedly since 1955, there was little change in the susceptibility
of staphylococci to the drug.7

Characteristically wide in its antibacterial spectrum, CHLOROMYCETIN has also proved valuable
in surgical infections caused by other pathogens-both gram-positive and gram-negative.7-8

CHLOROMYCETIN (chloramphenicol, Parke-Davis) is available in various forms, including
Kapseals" of 250 mg., in bottles of 16 and 100.

See package insert for details of administration and dosage.

Precautions: It is essential that adequate blood studies be made during treatment with the drug. While blood
studies may detect early peripheral blood changes, such as leukopenia or granulocytopenia, before they become
irreversible, such studies cannot be relied upon to detect bone marrow depression prior to development of
aplastic anemia.

References: (1) Minchew, B. H„ & Cluff, L. E.: J. Chron. D/s. 13:354, 1961. (2) Wallmark, G„ & Finland, M.: Am.J.M.
Sc. 242:279, 1961. (3) Wallmark, G„ & Finland, M.: J.AM.A. 175:886, 1961. (4) Welch, H„ in Welch, H, &
Finland, M.: Antibiotic Therapy for Staphylococcal Diseases, New York, Medical Encyclopedia, Inc., 1959, p. 14.
(5) Hodgman, J. E.: Pediat. Clin. North America 8:1027, 1961. (6) Bauer, A. W.; Perry, D. M., & Kirby, W. M. M.:
J.AM.A. 173:475, 1960. (7) Petersdorf, R. G„ et at.-. Arch. Int. Med. 105:398,

1960. (8) Goodier, T. E. W, & Parry, W. R.: Lancet 1:356, 1959.

90262 PARKS. DAVIS A COMPANY. Detroit 37. Michigan

PARKE-DAVIS

when postoperative infection
complicates convalescence...

CHLOROMYCETIN

(chloramphenicol, Parke-Davis)

for broad antibacterial action

Vol. LI I JULY, 1962 No. 7

CONTENTS

The President’s Address: Problems in the Practice
of Medicine in Iowa

Otto N. Glesne, M.D., Fort Dodge .... 389

President-Elect’s Address

George H. Scanlon, M.D., Iowa City . 393

Certified by the American Board: A Colloquy

Glenn S. Rost, M.D., Lake City 395

SCIENTIFIC ARTICLES

Medical Civil Defense: Are We Prepared?

M. E. Alberts, M.D., Des Moines 397

Physical Aspects of Radiation
Howard B. Latourette, M.D., Iowa City . 399

Radiation Pathology

Harold E. Resinger, M.D., Lexington, Kentucky 404
The Management of Radiation Casualties

Paul From, M.D., Des Moines 406

Fire Safety in the Hospital
Ed. J. Herron, State Fire Marshall .... 410

State University of Iowa College of Medicine
Clinical Pathologic Conference 412

EDITORIALS

Our Elderly Aren’t All 111 423

Pneumonia Still Poses Difficult Problems 423

Praise for Dr. Blanding 425

New Trend in Physician-Clergyman Cooperation 425
Glomerulonephritis and Impetigo ..... 426

Fifth Column 427

SPECIAL DEPARTMENTS

In the Public Interest facing page 420

Coming Meetings 421

Letter to the Editor 422

President’s Page 428

Journal Book Shelf 429

Hearing Conservation 431

The Doctor’s Business 433

Iowa Chapter of the American Academy of Gen-
eral Practice 434

State Department of Health 437

Iowa Association of Medical Assistants . . 439

Woman’s Auxiliary News 440

Minutes of the 1962 Annual Meeting .... 443

Index to the Minutes 498

IMS Officers and Committees, 1962-1963 . 499

County Medical Society Officers 502

Membership Roster of the Iowa Medical Society,

1962 503

Fifty Year Club Members 513

Membership Roster of the Woman’s Auxiliary to

the Iowa Medical Society 515

The Month in Washington xxix

Personals xxxv

Deaths xlvi

MISCELLANEOUS

Physician Population Boosted by 4,500 . . 409

National Bilirubin Survey 430

Committee to Run Medical School ... 432

In Memoriam: W. A. Sternberg, M.D 432

Some Children Resist Respiratory Bacteria . 434

Outstanding General Practitioner 435

Presentation of Awards 436

State Department Seeks Health Teams for

Viet Nam xxx

1962 Golf Tournament xxx

Where America’s Aged Live xxxii

EDITORS

Dennis H. Kelly, Sr., M.D., Scientific Editor Des Moines

Edward W. Hamilton, Ph.D., Managing Editor

Des Moines

SCIENTIFIC EDITORIAL PANEL

Walter M. Kirkendall, M.D Iowa City

Floyd M. Burgeson, M.D Des Moines

Daniel A. Glomset, M.D Des Moines

Robert N. Larimer, M.D Sioux City

Daniel F. Crowley, M.D Des Moines

PUBLICATION COMMITTEE

Samuel P. Leinbach, M.D Belmond

Otis D. Wolfe, M.D Marshalltown

Cecil W. Seibert, M.D Waterloo

Richard F. Birge, M.D., Secretary Des Moines

Dennis H. Kelly, Sr., M.D., Editor Ex Officio Des Moines

Address all communications to the Editor of the Jour-
nal, 5 29-36th Street, Des Moines 12

Postmaster, send form 3579 to the above address.

The President's Address

Problems in the Practice of Medicine in Iowa

OTTO N. GLESNE, M.D.

Fort Dodge

At the beginning, I should like to say that I am
aware of the rather pungent remark Dr. Anton J.
Carlson made when he arose to comment on a
paper before the American Physiological Society:
“What we need is more dogs, less words.” I hope
I can be brief and to the point.

At no comparable time throughout the whole
history of medicine, can one say there have been
so many changes in the practice of medicine as
have occurred in the last 50 to 60 years. From the
beginning of this century up to the present, there
has been a burst of scientific knowledge greater
than at any time in the past. Associated with this,
and at the same time, there has been a great burst
of socioeconomic changes. In 1959, Leo W. Sim-
mons, Ph.D., professor of education at Columbia
University, made a list of the problems of a socio-
economic nature that can be said to affect inter-
personal and inter-professional relations in medi-
cine: 1. increased mobility of population; 2. in-
creased sophistication of the population, sometimes
to the degree that the patient tries to tell you
what to do; 3. the general impression that the
medical profession has become commercialized;
4. the shift in age composition and prevalence of
disease in the population; 5. changes from a re-
ligious and philosophical orientation to a scientific
attitude toward life; 6. the development of pres-
sure groups within the structure of society.1

RECENT CHANGES IN MEDICAL PRACTICE

Within the more specific area of the practice of
medicine, but still socioeconomic in character, one
might list the following changes. Expansion in the
equipment and capital investment necessary to
practice medicine has proceeded at such a rapid
rate that one can hardly comprehend the magni-
tude of the increase. For example, at the present
time the hospitals are building on the ratio of 650
square feet per bed, and the hospital in the near
future will contain 900 to 1,000 square feet per
bed, whereas 20 years ago it was thought necessary

to provide no more than 250 square feet per bed
in order to render all services to the patient. -

Another change has been in the increase in spe-
cialization, with its natural accompaniment, split-
ting up of individual responsibility. This increase
in specialization, along with the rapid increase in
medical and paramedical specialties and their em-
ployment in rendering varied types of services to
the patient, has subdivided medical care into vari-
ous areas of responsibility, with a requirement for
pay, with a requirement for prestige, and with a
resultant feeling that the specialist tends to learn
more about less and less in the field of disease.

Another change has been the rapid growth of
prepayment plans and group medical plans, and
the greater participation not only by government
but by various segments of society, as for instance
labor, in the provision of medical care.1

All of these have resulted in a rather marked
state of confusion, to the extent that there has
been a profound effect on the medical — profes-
sional— patient relationship. The present practic-
ing physician finds himself in a bind. How much
time shall he devote to Blue Shield problems?
How much time shall he devote to the political
aspects of medicine? With politics becoming so
much involved in the medical care problem, is not
the future of medicine so much affected that he
must take part in political activity? How much
time shall he devote to hospital problems and to
the encroachment of the hospital in the practice of
medicine? How much time shall he devote to so-
cial welfare programs and to the development of
care programs attendant thereto? To what degree
shall he acquiesce in the establishment of fee
schedules? To what degree shall he cooperate with
Blue Shield in providing care for those over 65 at
a reduced fee? Is it desirable to have government-
sponsored care for persons over 65, such as the
King- Anderson Bill would provide? Is not the
presently-existing Kerr-Mills Law more desirable,
even though it is another vendor payment pro-
gram?

Less socioeconomic, but more within the area
of medicine, are such matters as the osteopathic
problem; the group practice pharmacy problem;
Blue Shield medical relations; relative value fee
schedules; the Medical School at the State Univer-
sity of Iowa, and its relationship to the medical

389

390

Journal of Iowa Medical Society

July, 1962

profession in Iowa, to government-sponsored re-
search, and to the medical care needs of the vari-
ous communities in Iowa; and a whole host of
other more or less minor, but nevertheless im-
portant questions. The over-all number of ques-
tions, the importance of each of them, the slow-
ness of solution, the resulting differences of opin-
ion, the time required to assimilate knowledge, the
time required for investigation — all of these final-
ly wear the individual practitioner down to the
point where he exclaims, “Oh! if I could just be
left alone to practice medicine!”

Unfortunately this cannot be, for these factors
and others vitally affect the practice of medicine,
and also vitally affect what he, the average in-
dividual practitioner in medicine, holds dear.

DOCTORS ARE CONCERNED ABOUT THE ELDERLY—
AND ABOUT ALL OTHER GROUPS

With the aforementioned changes in mind, and
with a desire to contact as many as possible of the
members of the Iowa Medical Society in a personal
way and at the grass roots level, 1 have attended
meetings of 45 of the 90 county medical societies in
Iowa, and have had informal discussions with the
member physicians on many of the questions men-
tioned above. There are more than 2,209 dues-
paying members in the Iowa Medical Society.
During these visits I had the opportunity of visit-
ing with a sizeable portion of the membership at
their home bases. I should like to summarize some
of the impressions I gathered during those visits.

I shall not give you a summary of all areas of
discussion, but should like to limit myself to the
three areas most frequently discussed and to
which more time was given than to the other less-
important ones. A large amount of time was de-
voted to vendor payment, government influence in
medicine, and the King-Anderson legislation now
before Congress. The large majority of our mem-
bers— and by this I mean more than 95 per cent
of them — resent the gradual intrusion of govern-
ment into medicine, and medicine’s concomitant
loss of free-enterprise status.

The degree of willingness to cooperate and the
quality of interest in the vendor payment pro-
grams such as Old Age Assistance, Aid to De-
pendent Children, and Aid to the Blind may vary
from county to county, but the overall majority of
our members are trying to render quality service
and care to such people at a reduced fee. Often
the medical profession is accused of over-charging
in connection with these programs. A bit of sta-
tistical evidence that might interest you is the
fact that during the month of August, 1961, when
there were over 13,000 medical bills submitted to
the Board of Social Welfare of Iowa, only five out
of these 13,000 statements presented by some 1,000
doctors were referred to the Medical Society for
review. Of those five, two had been presented by
one individual, and the other three, by three in-
dividual practicing physicians. Thus, in that par-

ticular month in 1961, less than one-half of one
per cent of the practicing physicians who sub-
mitted bills could be suspected of over-charging.
Even though many of these men who submitted
bills did not wholeheartedly approve this type of
program, they nevertheless did and do cooperate.

DOCTORS UNITE IN OPPOSING MEDICAL CARE
UNDER SOCIAL SECURITY

I can assure you also that the impression I
gained was that if socialized medicine in the form
of Social Security Tax attached medical care ever
becomes a reality, the cooperation will not be
anything nearly as good. The addition of care for
those over 65, financed by Social Security Tax, as
is proposed in the King-Anderson Bill, will be very
strongly opposed. I hesitate to give an exact figure,
but I can assure you that of the physicians who
would be involved, according to the now-existing
draft of the King-Anderson Bill, less than 50 per
cent would participate by submitting bills to the
Social Security Administration for services ren-
dered. At the same time I also can assure you that
the aged will be taken care of in any event, even
if the doctors have to provide all care gratis.

There is general agreement that the King-Ander-
son Bill is socialized medicine. There is general
agreement that the King-Anderson Bill satisfies
the definition of socialized medicine in Webster’s
new collegiate dictionary: “Administration by
an organized group, a state, or a nation of medical
and hospital services to suit the needs of all mem-
bers of a class or classes, or all members of a
population, deriving funds from assessment, and
taxation.” Social Security Tax attached medicine,
such as the King-Anderson Bill, would of neces-
sity have to be administered by the Social Security
Administration in Washington, with benefits that
could be changed frequently by politicians, and/or
rules of the Administration. The Social Security
structure, as it now stands, has become a political
football, with ever-increasing benefits being al-
lowed by each new Congress. This would be true
of medical benefits. As proof of this I should like
to quote Senator Pat McNamara’s Report to the
People of Michigan, dated September, 1961, 3 in
which he says the following concerning new bene- i
fits provided with the passage of PL 87-64 in 1961:
“My own view is that even this higher benefit level
is pitifully inadequate, and I shall continue to
work for further increases in the future.” The ulti-
mate end of this type of philosophy would have to
be either an increased tax percentage for Social
Security purposes, resulting in unbearable Social
Security taxes to the employer and employee, or
a defunct Social Security Fund that would not
even be able to pay benefits out of current income.

The members of the IMS also believe in the fol-
lowing statement from the Jewkes report on the
British National Health Service,4 in light of the
12 years’ operation of that program: “The average
American now has more medical service than the

Vol. LII, No. 7

Journal of Iowa Medical Society

391

average Briton and . . . the gap between the two
countries is widening. It is reasonable to suppose
that even without a National Health Service, Brit-
ain would have enjoyed, after 1948, medical serv-
ices more ample and better distributed than those
which existed before the war.”

The members of the IMS object to socialized
medicine for other and better-known reasons such
as deterioration of medical care; deterioration in
the quality and type of young people applying for
entrance to our medical schools; and the ever-
increasing tendency to centralize control in Wash-
ington, with no control at home. Iowa doctoi's ask
the question: “Why tax all employees with low
incomes to pay benefits to elderly people regard-
less of need?” Finally, Iowa doctors believe the
proposed King-Anderson Bill would establish a
new precedent, in that services rather than money
would be provided as benefits, and this is the first
time that such would be the case.

There is no question that the majority of the
members of the Iowa Medical Society feel that the
King-Anderson Bill, if passed, would be a foot in
the door, and that further and further attempts to
cover more and more segments of society would
certainly follow. They are in full agreement with
a statement attributed to Anuerin Bevan, who was
Minister of Health in Britain in 1950. When asked
how he intended to get control of the British Medi-
cal Association, Mr. Bevan said: “We have gotten
the hospitals, and that means we will control the
doctors. They can’t practice without places to
practice.” H.R. 4222, if adopted, would give control
of hospitals to the U. S. Government, and Mr.
Bevan’s words only confirm the AMA’s contention
that this Bill would open the door for the establish-
ment of federal controls over the practice of medi-
cine.

RAPPORT BETWEEN DOCTORS AND BLUE SHIELD
MUST BE PRESERVED

The second topic which consumed a great deal of
time at these county medical society meetings was
Blue Shield. The opinion was frequently expressed
that Blue Shield and Blue Cross sales representa-
tives do not know that Blue Shield was organized
by practicing physicians and that its membership
still consists of physicians — in other words, that it
is the doctors’ organization. Much criticism is
levelled at Blue Shield because of this departure
from the original concept of physician sponsorship,
and suggestions have frequently been made by
professional as well as non-professional people that
practicing physicians should divorce themselves
from Blue Shield.

It must be understood, however, that this par-
ticipating membership consisting of physicians is
the one feature that places Blue Shield in an en-
viable position in relationship to all strictly com-
mercial companies. The advantage consists in Blue
Shield’s being able to sell to the public full-service
contracts, which no other company can do. This

was established in the beginning, and it is still the
motive for the existence of Blue Shield, namely
that the patient shall have the benefit of full serv-
ice, if and when his income falls within the stated
limits.

I think it is highly improper to assume that this
benefit to the patient is also a benefit to the prac-
ticing physician. If you could have been present
and could have heard the amount of criticism that
full-service programs evoked from practicing phy-
sicians, you would undoubtedly agree that Blue
Shield does not exist for the benefit of the phy-
sician. It is for this reason that a strong relation-
ship exists and should continue to exist in the
form of the liaison committee between Blue Shield
and the Iowa Medical Society. Take away the full-
service contract privilege from Blue Shield, and
you would have an organization which would be
no better or different from any other insurance
company, and Blue Shield would have to be an in-
demnity company.

Organized medicine started Blue Shield. Organ-
ized medicine is the backbone of Blue Shield, and
Blue Shield cannot exist without physician sup-
port. Therefore, it becomes imperative that efforts
should be made by the Iowa Medical Society and
by Blue Shield to understand and convey to each
other the opinions of the respective organizations
through their respective representatives. This will
allow for better understanding and better relation-
ships, to the ultimate benefit of the patient-policy-
holder of Blue Shield. This can best be done
through the presently existing liaison committee.

OUR COLLEGE OF MEDICINE SHOULD REEMPHASIZE
ITS TEACHING FUNCTIONS

The third and final area of discussion on which
I wish to report to you has to do with the Medical
School of the State University of Iowa. Dr. Virgil
Hancher, president of the State University of Iowa,
in an address to service clubs in Iowa City in
January of this year stated: “Universities are

complex institutions containing professional and
graduate programs, whose generally accepted ob-
jectives are teaching, research and service. Uni-
versities, like other institutions, transmit through
teaching the culture and the accumulated knowl-
edge of the race. Universities not only discover
new knowledge; they are or should be its dissemi-
nators and interpreters.” I should like to have you
note that Dr. Hancher listed teaching as most im-
portant.

Dr. Walter Bauer,5 in an address at the 150th
anniversary of the Karolinska Institute, in Stock-
holm, Sweden, in 1960, asked the question: “How
can medicine care for the sick in its highest
humanitarian tradition and at the same time bring
to the patient the full weight and authority of
modern science?” He also asked the question:
“How can we avoid becoming specialists or gen-
eralists, and instead become specialists and gen-
eralists? Is it true that the only ones left to care

392

Journal of Iowa Medical Society

July, 1962

for the whole man are humanists, clergymen, and
general practitioners?”

In the winter, 1961, issue of the medical bulletin

OF THE STATE UNIVERSITY 07 IOWA COLLEGE OF

medicine, there is a list of grants that had been
given to the College of Medicine during the sum-
mer and fall of 1961. There was a total of $677,350
in grants to various departments from the United
States Public Health Service. During that time,
grants totalling $90,778 were received from vari-
ous philanthropic associations such as the Iowa
Heart Association, the American Cancer Society
and others. During the same time there was a
total of $49,236 received from industries, including
drug companies, the tobacco industry and other
organizations. Also during that time a total of
$1,690,000 was granted by H.E.W. to be used for
construction of a minimal-care unit and a research
building. It is true that the total construction costs
exceed those amounts, and that the funds are sup-
plemented from state sources. This preponderance
of federal funds, however, has raised questions in
the minds of many of the members of the Iowa
Medical Society. Is it possible that these large
donations of government funds may tend to create
in the minds of the members of the faculty a rather
friendly attitude towards socialization of medi-
cine? Do these large amounts of money devoted to
research remove the serendipity of the true re-
search worker? Does the influx of this great
amount of money tend to enlarge the resident staff
and student staff to the extent that the students
and the teachers are not oriented to the needs of
the practice of medicine? Does the increase in
staff organization and setup tend to remove the
heads of departments from teaching activities
which logically, and according to Dr. Handler’s
statement, should be their primary functions?
Which is more important, teaching or research?
Is the average student given knowledge of what
the medical-care needs are in the communities of
the State of Iowa?

Interesting and timely, but too recent to quote
extensively, is a j.a.m.a. editorial entitled “Scien-
tism: A New Blight.”6 I strongly recommend that
you read it, but I should like to quote one sentence
from it: “Medical educators have recently shown
some alarm at the progressive increases in re-
search money, since they have, rightly, suspected
that their own slim manpower resources are thus
being attracted elsewhere.”

In a rather interesting report, Drs. White, Wil-
liams and Greenberg7 made the following points:
Data from medical care studies in the United
States and Great Britain suggest that in a popula-
tion of 1,000 adults (16 years of age and over),
in an average month, 750 will experience an epi-
sode of illness, 250 of these will consult a phy-
sician, 9 will be hospitalized, 5 will be referred
to another physician, and one will be referred to
a university medical center. The university med-
ical center sees a biased sample of lzAm of one per

cent of the sick adults and Vio of one per cent of
the patients in the community, and from that mi-
nute sample students of the health professions must
get an unrealistic concept of medicine’s task at the
grass root level. Medical care research, they grant,
is necessary and the need for according it at least
equal priority with research on disease mechanism
is necessary. But they went on to suggest that it is
now time for schools of medicine, schools of public
health and teaching hospitals to address themselves
to the urgent need for medical-care research and
education. It is now time for the health profes-
sions, and particularly for faculty members with
clinical interests, to join their colleagues from
other disciplines in according to medical-care re-
search and teaching the same priority that they
have accorded research into the fundamental
mechanisms of pathologic processes. There is a
definite feeling among the physicians practicing
in Iowa, be they specialists or general practition-
ers, that there are a number of departments at
the S.U.I. College of Medicine that are not at-
tuned to, or cognizant of, real problems that face
the average physician in the various communities
of Iowa, be he general practitioner or specialist.

A CONTINUATION-STUDy CENTER IS NEEDED

One of the professors at the State University of
Iowa Medical School makes the following state-
ment in an often repeated address: “My theme of
the patient down through the long halls of time
has some lessons. Care, love, humanity, have al-
ways been the leaven which raises hope — the yeast
in the bread of life. Science, the ability to see
things as they really are, is essential to medicine,
but must not displace the grace of love which is
quintessential.”8 If the above statement is true,
is it not essential that the medical-care needs of
the communities, be they rural or urban, should
be given more consideration in the teaching of
students? And in the postgraduate area, is it not
essential for the medical practitioners to have a
continuing type of education in order to keep up
with advances in research, be they fundamental or
more practical? Many members of the Iowa Medi-
cal Society have the opinion that a continuation-
study center should be built in order that the med-
ical-care needs of the community may be trans-
mitted to the faculty at the medical school, and in
order that research and new knowledge may be
transmitted by the faculty to the practitioners out
in these various communities. The Iowa Medical
Society and the State University of Iowa Medical
School should work hand in hand towards a com-
mon meeting ground, in order to understand each
other’s problems. There should be an opportunity
for the faculty to become more interested in medi-
cal-care needs, and to dispel the impression often
reported at these meetings that I attended, namely,
“They’re interested only in training specialists.”
I am sure that the Iowa Medical Society would

Vol. LII, No. 7

Journal of Iowa Medical Society

393

welcome such an opportunity, and if given the im-
pression by the faculty that teaching is most im-
portant, and that teaching medical care is also im-
portant, the members of the State Society would
cooperate to a greater extent than has been
dreamed possible.

CLINICAL MEDICINE IS STILL MOST IMPORTANT

There should be an attempt by the Medical
School to dispel the impression that the faculty is
self-sufficient, and need not be concerned about
medical-care needs. The physicians in Iowa do
not feel that medical-disease research, pure and
simple, should be forgotten, but that it should be
relegated to its proper perspective in relationship
to the medical-care needs of the average practi-
tioner and of his community. Then it might be
possible to live up to the advice that Governor
Ernest Hollings of South Carolina gave in a com-
mencement address at the Medical School of South
Carolina: “Remember the patient. Keep all other
demands in perspective. Never stop improving
yourself professionally. You must pursue perfec-
tion in medicine, and mold your lives after the
magnificent men you follow, and the Great Phy-
sician whom all men follow. While research has

President- El

GEORGE H. SCANLON, M.D.

Iowa City

Because of my many years in organized medicine,
most of them spent on your Board of Trustees
where one really learns all the problems of our
Society, I assume your presidency with a full
realization of the serious and complex problems
that we face this year. I only hope and pray that
my experience will prove fruitful.

I have one advantage over most incoming presi-
dents in that, since the annual meeting is occurring
in May rather than in April, I can share with them
the honor of holding office, but have one month
less in which to shoulder the accompanying re-
sponsibilities. I have just 11 months to go. Never-
theless, it is quite likely that sometime during my
short term, medicine’s destiny will be determined.

In his presidential address, Dr. Glesne has pin-
pointed the many difficulties that confront the
Iowa Medical Society, and has brought you up to
date on what has been done during the past 13
months to cope with some of them. He has spoken

brought us miracle drugs and remarkable recov-
eries, there will be no discovery which will elimi-
nate the hard work of the doctor. Of all profes-
sions, the medical profession still calls for the
hardest work. You hold the highest power of pub-
lic trust. You also hold the greatest of opportuni-
ties as a profession to help the nation rid itself of
the equivocal man. Your profession stands as a
symbol of the finest achievement of American free
enterprise. The American medical profession has
brought this nation the world’s foremost record in
medical care and progress. This has been accom-
plished by the personal efforts of devoted men
and women.”

REFERENCES

1. Simmons, L. W.: Important sociological issues and im-
plications of scientific activities in medicine, J.A.M.A.,
173:167-171, (May 14) 1960.

2. Cunningham, R. M.: Hospital, doctors and dollars: ad-
dress to the 29th Annual Assembly of the Medical Society
of the District of Columbia.

3. Senator Pat McNamara’s “Report to the people of Mich-
igan,” Sept. 1961.

4. Jewkes, J. and S.: Genesis of the British National

Health Service. J.A.M.A., 179:215-216, (Jan. 20) 1962.

5. Bauer, W. : Responsibility of the university hospital in
synthesis of medicine, science and learning. New England J.
Med., 265:1292-1298, (Dec. 28) 1961.

6. Editorial: Scientism: new blight. J.A.M.A., lSO:155-156,
(April 14) 1962.

7. White, K. L., et al.: Ecology of medical care. New Eng-
land J. Med., 265:885-892, (Nov. 2) 1961.

8. Bean, W. B.: Patient’s pilgrimage through medical his-
tory. Arch. Int. Med., 180:548-558, (Oct.) 1961.

s Address

of the past and of the present; I want to talk
briefly with you about the future.

MEDICAL CARE FOR THE ELDERLY IS OUR MOST
IMMEDIATE CONCERN

I am sure you will agree with me that financing
health care for the aged is our foremost and most
serious problem. Many bills have been introduced
in Congress, and of them, the Kerr-Mills Bill, has
already been enacted into law. It is the one meas-
ure of which the doctors all wholeheartedly ap-
prove. The public and all taxpayers should also
approve it for the following reasons:

First: It is a program of federal-state matching
funds, and under it the states and local communi-
ties determine who really needs help. Who knows
better than you or I who really needs help?

Second: We know that under the Kerr-Mills
Act, the taxpayers’ money is to be used only in
helping the needy, and the taxpayer deserves that
protection.

Third: The cost will be less in the end, for of
every dollar put up for the aged in Iowa, the fed-
eral government is to pay 58 cents and our state
government is to pay the remaining 42 cents.

394

Journal of Iowa Medical Society

July, 1962

Now let’s look at the King- Anderson Bill — the
proposal backed by the President of the United
States.

First: It would all be financed by Social Secu-
rity, but the sad part of it is that four million of
the people past 65 years of age in the United States
can’t qualify for Social Security benefits and,
therefore, wouldn’t he eligible. Who would take
care of them?

Second: Along with some of the indigent and
near-indigent, the King-Anderson proposal would
take care of the rich and all others who though
not affluent, are nevertheless well able to take
care of themselves.

Third, the cost: At the outset the Social Secu-
rity tax on both employers and employees would
be raised V4 of 1 per cent, and the limit on taxable
earnings would be raised from $4,800 to $5,200.
Do you realize that even without the King-Ander-
son Bill, the Social Security tax schedule will reach
9 per cent on the first $4,800 by 1969?

In all honesty, the President of the United
States and his followers will have to admit that
this Bill is nothing more than a political gimmick
— a device to get votes rather than a carefully
drawn and well considered attempt to help the
unfortunates among our fellow citizens. It is a
foot-in-the-door maneuver that will quickly lead
to the socialization of medicine. The President’s
ultimate objective, of course, is to concentrate
more and more poioer in the federal government.
If the above facts are not correct, why does he
forget the four million people not covered by
Social Security? Why does he not accept the
Kerr-Mills Act, which is already law and which,
as I pointed out, cares for everyone over 65 who
really needs help?

Gentlemen, I cannot imagine that our legislators
in Washington will acquiesce in such an unfair
piece of legislation, if considerable numbers of
people support them in opposing the President’s
wishes. Therefore, it behooves you and me to
acquaint all of our patients with these facts, and
to ask them to express themselves personally to
their Congressmen and Senators. Remember, we
have a serious handicap — we cannot match the
funds of the federal treasury and the prestige of
the President.

A KERR-MILLS PROGRAM MUST BE STARTED IN IOWA

It is not enough for us merely to oppose the
King-Anderson Bill. Rather, we must present an
alternative that will do two things: (1) measure
the need for medical aid to the aged, and (2) estab-
lish an economical program for meeting the need.
In Iowa, we have such an alternative. During the
1961 session of the General Assembly, the IMS
and its many allies secured the adoption of the
Kerr-Mills Implementation Act, but the reluctance
of our legislators to increase taxes, together with
their doubts regarding the need for such a pro-
gram, prevented the passage of an appropriation
for it. Following the defeat of the King-Anderson

Bill, the obtaining of funds for the implementa-
tion of Kerr-Mills must be the number-one ob-
jective of the Iowa Medical Society.

Unified action by all who are interested in pre-
serving the private system of medical care will be
necessary if we are to convince the General As-
sembly of Iowa that it should dip into the Iowa
treasury to finance health care for the needy aged.
It won’t he easy. As was true in getting the Kerr-
Mills Implementation Act onto the books, the IMS
will probably have to take the leadership in re-
questing funds to put the 1961 law into effect.

WE'LL HAVE OTHER PROBLEMS AND PROJECTS

There are many legislative problems that the
IMS will have to deal with during the next year,
particularly since the Legislature will be in ses-
sion next spring. These will concern radiation con-
trol, tort immunity for physicians offering emer-
gency care, professional corporations, confidential-
ity of medical records, and other subjects that
will no doubt be brought up at the time of the
next General Assembly.

As a member of the IMS Board of Trustees for
several years, I have been closely associated with
the headquarters staff and have been able to ob-
serve at first hand the growth that has occurred
in the work of our Society. The number of em-
ployees has not increased in proportion to the
growth in the work load, and frankly, too much
is expected of our staff members. I fully realize
that, since our income is restricted, and our budget
must consequently be limited, we must proceed
with caution. However, it sems to me that the
least we can do is to provide our staff with ade-
quate room in which to work. I assure you that
I shall take a great personal interest in any future
plans of the Society to construct a new home of-
fice building. I want to assure you at the same
time, however, that any plans for a new building
will be carefully drawn, and will be acted upon
only after proper consultation with the appropri-
ate bodies of the Society.

REORGANIZATION OF IMS COMMITTEES

One other project that I hope to carry out
through the Plan and Scope Committee is a study
of the structure and activities of the 49 Standing
and Special Committees of the IMS. I am par-
ticularly interested in determining whether or
not the committees are properly coordinated, and
that all areas of interest are covered. Some inter-
est has been shown in the establishment of a com-
mission similar to the one which exists in Wis-
consin, to serve as a liaison with state and federal
departments. If it is determined that such a com-
mission would be the best approach to our rela-
tions with these states and federal agencies, it
is conceivable that we could bring under such a
commission the committees on public health, men-
tal health, automotive safety, etc. I expect to ask
the Plan and Scope Committee to begin work at
once on the project, and I hope that its study can

Vol. LII, No. 7

Journal of Iowa Medical Society

395

be completed in time for a report at the next an-
nual meeting. The changes will be effected, how-
ever, only if they seem desirable and acceptable
to the House of Delegates. If such a plan is
adopted, changes may have to be made in the
basic organization and rules of the Society, and
of course, we would expect to confer about them
with the members of the Committee on Articles
of Incorporation and By-Laws.

For the reasons just mentioned, only a limited
number of changes are being made this year in
the personnel of the IMS committees. The lists of
appointments have been prepared and will be
published in the July issue of the journal of the

IOWA MEDICAL SOCIETY.

I hope that when I report to you in April, 1963,
it will be with pride that many of our aims have
been accomplished.

Certified by the American Board:

A Colloquy

GLENN S. ROST, M.D.

Lake City

The afternoon was cool. The sky was slightly over-
cast. Thirty-fourth street was all but abandoned,
and I had an ideal opportunity to saunter past the
remnants of what had been “Old Blockley” in the
days when I was associated with the Hospital of
the University of Pennsylvania, next door.

But no! There he was again — the same figure I
had noted a short time earlier, walking deliber-
ately but purposefully. He was an elderly white-
haired man, almost bald but with a rather full
and distinctive white mustache, a striped necktie,
fine pince-nez glasses, and with — could it be? —
pin-striped trousers, a notably long coat and cut-
away tails suggestive of a bygone era of aristoc-
racy.

I was first to speak: “Sir, can I assist you?” His
penetrating gaze was at first my only answer. Then
slowly and deliberately he cleared his throat as
though to speak, hesitated again, and then spoke
in a sharp, punctilious voice well suited to the
man before me.

“Yes. What are these buildings? This is not
‘Old Blockley.’ What has become of that famous
place? Where is the spacious lawn filled with re-
cuperating patients? Where are the soldiers in
blue, the nurses, the doctors? Where, my new
friend, is Sir William? Where is his ‘Dead House’?
Perish the name but pay tribute to its function.”

Quickly my mind reverted to my old associa-
tions with the area. It must be, I thought, that he
refers to Sir William Osier and to his famous
morgue and autopsy room. He speaks as if he
knew Sir William very well. “If by chance you
mean Sir William Osier,” I answered, “you must

Dr. Rost presented this paper at the fall meeting of the
Iowa Academy of Surgery, in Iowa City, in 1961.

surely know that he has been dead for many
years.”

“Yes, yes, I know,” came the impatient reply,
“but Sir William and I had a tryst — a tryst to re-
turn and meet on this very spot at this very hour,
to discover if perchance our teachings and precepts
had endured.”

“But, Sir—”

“If perchance you see him,” he interrupted, “just
convey to Sir William that William Stewart Hal-
sted is on time.”

I knew then to whom I spoke. This was no
seance. We were not spirits meeting in a dream
world. No, this was reality — Thirty-fourth and
Spruce Street in old Philadelphia. This was the
Municipal Hospital — “Old Blockley,” it was called,
a teaching area enshrined 50 years ago by Dr.
Osier’s indefatigable energy and enthusiasm. Be-
fore me stood a surgeon of Sir William’s era, re-
turned to reevaluate a well organized residency
training program.

Dr. Halsted turned as though to go, hesitated,
and then almost apologetically asked, “Do the gen-
eral surgeons still think well of my incision and
technic for radical mastectomy?” Assured that
they still do, he seemed relieved, but he betrayed
some concern when I added gently that from time
to time the OB-Gyn men have been known to use
his incision and technic, feeling that surgery of
the breast, since it is performed upon women,
should be done under the aegis of their specialty.

“You mean,” he countered, “that surgery has
been subdivided according to the sex of the pa-
tient?” My reply started a discussion of the urol-
ogist and the limitations of his field. A canny twin-
kle appeared in his eye when I said that hypospa-
dias lies within the province of the plastic surgeon.
He had heard of materials called “plastics,” he
said, but had failed to see their usefulness in sur-
gery.

“Plastic surgery,” I explained, “is a type of sur-
gical work, rather than a reference to the fact

396

Journal of Iowa Medical Society

July, 1962

that the materials loosely referred to as plastics are
sometimes used in surgery.”

Incredulous, my new friend inquired, “Am I to
understand that there now is a group of men who
do no work other than revision and reconstruc-
tion?”

As we approached the steps of Philadelphia’s
Municipal Hospital, I explained that we now have
19 specialty boards and over 50 specialties and sub-
specialties, and that since 1930 various programs
of certification of ability and training have been in
effect. But problems of increasing magnitude have
arisen out of jurisdictional disputes in which a
hungry or jealous doctor has encroached upon
another’s domain.

The twinkle in the old man’s eye brightened as
I pointed out that the obstetrician, though quite
capable of caring for the mother and baby through
confinement, nowadays becomes incompetent to
do so, once the baby is born, and hence a new
group known as pediatricians assume command.
This is, of course, quite fitting and proper until
the child is found to have a congenital anomaly
requiring surgery, whereupon the principles of
certification require that a pediatric surgeon must
take charge. Even the serenity and seeming sta-
bility of these well-demarcated jurisdictional lines
are quickly shaken when it is discovered that the
child is a boy and has an easily diagnosed and com-
mon congenital lesion— an elongated foreskin. Alas,
who should do the surgery — obstetrician, pedia-
trician, pediatric surgeon, plastic surgeon? ... No,
the child is Jewish, and all jurisdictional lines must
yield to the rabbi’s knife!

Sensing the irony of all this, my new friend
subtly inquired about surgery of the neck, and
laughed aloud when I pointed out that the nose
and throat man considers this his domain, that
the thoracic surgeon argues it is but an extension
of his area, and that the endocrinologist hastens
to indicate that at least the thyroid, the parathy-
roids and the carotid bodies are endocrine in type.

Knowing the fame achieved by Dr. Halsted in
the technical management of cancer of the breast,
I indicated that at least there the general surgeon
is still in charge, but that his domain is rapidly
being challenged by a group who deal entirely
with tumors and new growths. And though the
conflict hasn’t yet arisen, one wonders when the
thoracic surgeon will claim this field as a part of
his domain.

Dr. Halsted asked about the gastrointestinal
tract and learned that the thoracic surgeon feels
that the esophagus belongs to the thorax, even
though it does transport nutritional elements from
the mouth to the realm of the gastroenterologist.
The proctologist considers the large bowel as only
a continuation of the rectum, and therefore his
property. When I pointed out that the last remain-
ing stronghold of the general surgeon is again

being challenged — this time by a group known
as the abdominal surgeons — my friend sorrowfully
shook his head and again turned as if to go. Al-
most as an afterthought, he asked me, “What of
the internist? Has his preserve been partitioned
too?”

“It has,” I replied regretfully, but hastened to
add that in many ways the internist is becoming a
glorified interne in a higher tax bracket. The pres-
ent feudal system requires him to complete the
preoperative physical clearance for the EENT
man, the gynecologist, the general surgeon and
the orthopod, but the real diagnostic studies must
be done by the cardiologist, the hematologist, the
gastroenterologist or a specialist of some other
type. This arrangement, I pointed out, leaves the
internist an opportunity to diagnose and treat the
common cold, provided that it has not occurred in
a child under 12 years of age, when it becomes the
responsibility of the pediatrician, or in one of his
arthritic patients currently being supervised by
the referring general practitioner.

The low back pain resulting from a disc syn-
drome might wind up in orthopedic surgery, where
the patient would receive a back fusion, or per-
chance might find its way to the neurosurgical
service, all depending on the fates of that day.

“And,” he asked, “what becomes of the man who
falls from his horse or carriage and fractures a
femur?”

Facetiously, but gently, I pointed out that horses
and carriages have been replaced by much more
lethal weapons, such as autos, airplanes and jets.
“However, in the event of survival,” I added, “the
rules of specialism require that this patient be
transported the necessary miles to an orthopedist.
If he is still alive on arrival at the medical center,
he will be seen by an internist, who will decide
that he doesn’t have a cold; by a nose and throat
man, who will reduce his fractured nose; by a
neurosurgeon, who will supervise his deepening
coma; by a thoracic surgeon, who will care for
his fractured ribs and lacerated lung, while an
anesthesiologist provides him an airway; and the
orthopedist, who will place the necessary fixation
on or in his fractured femur. Finally, someone will
discover that he may have an abdominal injury,
and the general surgeon is called. But lo, the gen-
eral surgeon cannot reach the patient’s side be-
cause his conferees, the specialists, are there in
depth! Who is in charge? No one knows.”

The dapper old man turned once more to go,
and sadly shaking his head, he spoke softly: “Tell
Sir William that I departed, not to return until
these men whom, you call ‘specialists’ have ac-
knowledged the unity of the human body.”

I perceived a sudden change — the television
program was barely discernible. Osier’s autobiog-
raphy had fallen from my lap. It had been a pleas-
ant dream.

Medical Civil Defense
Are We Prepared?

M. E. ALBERTS, M.D.
Des Moines

Four papers appear in this issue of the journal
of the iowa medical society which should serve
to stimulate our thoughts in answer to the ques-
tion, “Are we prepared?” One of the many facets
of preparedness for disaster is the problem of
radiation. Three of these papers discuss radiation —
what it is, and what it can do, and what we can
do about it.

Interest in national preparedness waxes and
wanes with the climate of international news.
Several months ago when international relation-
ships became tense in the Berlin area, great im-
petus came about to build fallout shelters, to
learn more of radioactive fallout, and to stock-
pile emergency supplies. Then, in a matter of
several weeks, fears began to subside, interest
waned, and we resumed our casual daily way of
life. Other crises will arise, interest will be re-
vived, and the entire cycle will be repeated. But,
one fact remains. If world conditions remain much
as they are, we cannot totally dismiss the concept
of being prepared for an eventuality that we hope
will never occur — i.e., actual nuclear warfare. For
such a catastrophe would mean mass destruction
in many areas of the world.

DOCTORS MUST TAKE THE LEAD

Can we survive a thermonuclear war? Certain-
ly, we can! But, not sitting down. It is particularly

Dr. Alberts is chairman of the IMS Committee on Emer-
gency Medical Service, and he served as moderator of the
panel discussion on radiation at the medical civil defense
conference in Oelwein, Iowa, on November 9, 1961.

important that doctors of medicine be well-
informed about the problems of survival and civil
defense. As respected members of their communi-
ties they can provide advice and example. They
understand the importance of prevention of mor-
bidity, and by virtue of their education and ex-
perience can exert the necessary leadership. Other
countries are prepared. Don’t Americans also de-
serve protection?

The physicians of Iowa can provide leadership
in civil defense activities, as well as in mobilization
for all other forms of mass-casualty situations.
Often pleas such as “too busy” or “don’t know
anything about it” are offered. The component
medical societies are to blame in that they fail
to provide initiative and to arouse interest among
their members.

HOSPITAL PERSONNEL HAVE EXCEEDED DOCTORS
IN THEIR SHOW OF INTEREST

Recently, a questionnaire was sent out to 16
Iowa county medical societies in a particular area
of the state. This questionnaire consisted of four
simple “yes or no” questions. Six county societies
did not bother to answer. Those that did reply
showed reasonable interest. The questions and
answers were as follows:

1. “Is your present County Medical Civil Defense
and Disaster Committee intact?” Yes, 7; No, 3.

2. “Have you met as a group in the past, and
if yes, the approximate date?” Yes, 6; No, 4.

3. “Have you set up a plan for handling of any
future disaster or emergencies?” Yes, 5; No, 5.

4. “Would you be interested in some type of
workshop at a centrally located area to discuss the
problems you might have?” Yes, 8; No, 1; No an-
swer given, 1.

Now, this last question is the important one.

397

398

Journal of Iowa Medical Society

July, 1962

If people are not interested, why not? Why does
a man accept responsibility for medical civil de-
fense in his community if he has no interest in
the problem?

Similar questionnaires were sent at the same
time to 21 hospital administrators in the same
area. All but one were returned. The answers on
these were as follows:

1. “Do you have a disaster medical care plan
set up for your hospital?” Yes, 14; No, 6.

2. “Have you carried through a trial run of this
plan?” Yes, 5; No, 15.

3. “Have you met in the past with your County
Medical Civil Defense and Disaster Committees?”
Yes, 10; No, 10.

4. “Has your hospital plan been integrated into
the county plan?” Yes, 6; No, 14.

5. “Would you be interested in meeting at a
centrally located area and having some type of
workshop to familiarize you with any problems
you might have on medical civil defense?” Yes, 20;
No, 0.

These were very enlightening responses. First,
they emphasized the need. Some hospitals have
no mass casualty plans at all, and fewer than half
of those that do have plans have any real idea of
their practicality. Fewer than half have integrated
their plans within the community plan. But, all
the administrators questioned are interested in
learning more.

MORE AREA CONFERENCES CAN AND SHOULD
BE HELD

A workshop was held at Oelwein, Iowa, in No-
vember, 1961, as a result of these questionnaires,
and the meeting proved to be very worthwhile.
Dr. D. J. Ottilie, representing the IMS Committee
on Emergency Medical Service, did a tremen-
dously fine job on local arrangements for the one-
day meeting. The afternoon session consisted of
a panel discussion on “The Role of the Health Pro-
fessions in Civil Defense and Disaster Planning,”
with members of the allied health professions
presenting their views on this provocative subject.
Films were shown on “Medical Effects of an
Atomic Bomb” and “Management of Mass Casual-
ties.” The papers on radiation presented in this
issue provided the evening program, which was
well attended by physicians, nurses, hospital ad-
ministrators and representatives of other health
professions.

Workshops of this type provide a real stimulus
to medical and community leaders to provide pro-
tection for the people of their respective communi-
ties. More such area workshops are needed, and
will be planned. There are many subjects of great
importance in the area of mass casualty manage-
ment which could be discussed.

THE MEDICAL SELF-HELP TRAINING PROGRAM

There is another area of preparedness into
which we physicians must enter, and again dem-
onstrate our leadership, encouragement and in-
terest. During recent months, the Medical Self
Help Training Program has been launched through
the coordinated efforts of the American Medical
Association and the Section of Health Mobiliza-
tion of the U. S. Public Health Service. This pro-
gram is designed for the general public, and its
goal is eventually to train one member of each
family in the United States in the basic principles
of self-help for survival. The course is in its pilot
stage at present, and is being very well accepted
at all levels.

Twelve topics are covered in the course:

1. Radioactive Fallout and Shelter

2. Hygiene, Sanitation and Vermin Control

3. Water and Food

4. Shock

5. Bleeding and Bandaging

6. Artificial Respiration

7. Fractures and Splinting

8. Transportation of the Injured

9. Burns

10. Nursing Care of the Sick and Injured

11. Infant and Child Care

12. Emergency Childbirth

Underlying the Medical Self-Help Training Pro-
gram is the philosophy that “knowledge replaces
fear.” A person who knows what to do when faced
with disaster will act rationally and effectively.
The unlearned person will react blindly and in-
effectively. The program is designed to give people
confidence in their ability to survive, along with
skills to make them self-reliant until medical
services are again available.

The practicing physician is a key figure in this
nationwide training program. He will be asked to
advise people in matters of medical self-help, and
to provide the professional leadership so necessary
for the successful accomplishment of this training
program.

The American Medical Association’s Report on
National Emergency Medical Care states that “it
is the responsibility of the medical profession . . .
to provide the leadership and guidance that will:

“Provide sound mass casualty planning at all
levels of government and at all levels within the
professional and health organizations.

“Encourage the population of the United States
to engage in individual and collective survival
training.”

We can be prepared! We can survive! Are you
willing to do your share?

Physical Aspects of Radiation

HOWARD B. LATOURETTE, M.D.

Iowa City

All of us have an interest in the fundamental ac-
tivities of our country and of the people of our
world in regard to “War” or “Peace.” The degree
of our interest varies with time and becomes
much more acute as the possibilities of “War” be-
come greater. We are more or less aware that
the nature of war has been drastically changed by
technologic advances, and that any total war now
includes the use of nuclear weapons. As we con-
sider the possibility of nuclear war and of the
catastrophic consequences of such a war, we are
increasingly interested in the Civil Defense effort
and, understandably, attempt to evaluate its po-
tential effectiveness and how it might involve us
as individuals.

SOME SERIOUS QUESTIONS

In my opinion, each individual needs to estab-
lish his own philosophy on the related issues of
war or peace, on foreign policy, on national de-
fense, on civil defense efforts, and on the various
shelter programs. To me, it seems unreasonable
to separate any one of these issues and attempt
to make any judgments regarding it without con-
sidering it in relationship to the others.

I find it helpful in trying to develop my own at-
titude toward these issues to consider the follow-
ing five generally unanswerable, but provocative
queries:

1. Do I realize how truly catastrophic an all-

out war would be? Radiation and fallout are only
two aspects of the massive destruction of life, or-
ganizations, countries, even cultures that can re-
sult from this type of war.

2. What do I hold so valuable that in an at-
tempt to preserve it, I would precipitate such a
war? I need to realize that there is a distinct pos-
sibility that what I am trying to preserve might
well be lost during such an encounter, even though
I eventually caused greater destruction than I re-
ceived.

3. What specific and active steps can I, as an
individual, take to help avoid such a war?

4. In spite of any actions that I might take,

Dr. Latourette, professor of radiology, State University of
Iowa, made this presentation at the Conference on Medical
Civil Defense held at Oelwein on November 9, 1961.

what are the chances of such a war? If I were to
decide that there was one chance out of two that
during the next ten years such a war is going to
take place, my life might be quite different from
what it would be if I were to decide that the
chances were only one in 100.

5. If such a war does occur, what can I do to
improve my chances for survival? Even though I
recognize that the chances are few, can I improve
them in any way?

We are all concerned with these questions,
whether we realize it or not. In the attempt to
gain some insight into them, we need constantly
to weigh the vast amount of written and spoken
material on these subjects, and to attempt to sep-
arate fact from opinion.

THE NATURE AND SOURCES OF RADIATION

In an effort to add to our factual knowledge on
one aspect of all-out war, I am to discuss the phys-
ical aspects of radiation. Radiation is a form of
energy which either is particulate in nature or is
electromagnetic. Electromagnetic radiation in-
cludes radio waves, light, x-rays, and gamma rays
which are emitted by radioactive nuclei. Under
certain conditions, either type of radiation can
cause changes in tissues, including death. The
changes in tissues depend upon the type of radia-
tion, the amount of radiation, and at what rate it
is absorbed.

Considerable factual knowledge has been accu-
mulated regarding the effects of radiation upon
man. One of the chief sources of radiation that
affects man, either in peacetime or in time of
nuclear war, is that which is associated with ra-
dioactivity. This is a process by which certain
atomic nuclei, which are unstable because of the
imbalance of the forces within the nucleus, emit
radiation, either particulate or electromagnetic.
The emission of this radiation is associated with a
reorganization of the nucleus, and it continues in
sudden steps until a stable, permanent state is
reached. All elements occurring in nature having
atomic nuclei that are very heavy and contain
many protons and neutrons are radioactive. Urani-
um and radium are examples of naturally-occur-
ring radioactive elements. Since the development
of nuclear reactors and of the capability of bom-
barding any atomic nucleus with neutrons, all
known elements have been made radioactive. All
of the more common elements with lower atomic
numbers, then, may be either stable or radioactive.

399

400

Journal of Iowa Medical Society

July, 1962

These various states of an element are spoken of
as isotopes. Each radioactive isotope of a given
element, and there may be more than one, has a
characteristic pattern of decay, or process of re-
organization of its nucleus. The energy of the
emitted radiation and the period of time necessary
for half of its atoms to go through the sudden step
of reorganization are so specific that they can be
used to identify the isotope. The time that half of
the atoms take to go through this reorganization
is spoken of as the half-life of the isotope. It may
be a fraction of a second for some isotopes, or mil-
lions of years for others. The half-life is a statisti-
cal concept, and averages the time of sudden
changes in individual atoms.

The emitted radiation from a radioactive nucleus
may consist of alpha particles, beta particles or
gamma rays, the characteristics of which are pre-
sented in Table 1.

TABLE I

RADIATION EMITTED FROM A RADIOACTIVE NUCLEUS

Description

Range in
Tissue

Absorbed by

! . Alpha particle

relatively
heavy particle
( Helium nucleus]

few microns

few sheets
paper

2. Beta particle

relatively light
particle
(electron )

1 -2 mm.

thin magazine

3. Gamma ray

E-M radiation
( no mass)

1 meter

4-6" lead or
3' packed earth

Usually, a radioactive nucleus emits either an
alpha particle or a beta particle at any one step,
and the particle may or may not be associated with
a gamma ray. Once an atomic nucleus becomes
radioactive, the process of decay or reorganization
of individual atoms proceeds at its characteristic
rate regardless of any physical or chemical change
in which the atom is involved.

When considering the biologic effects of radia-
tion— that is, the changes that radiation produces
in living tissues — one should recognize that man
cannot sense or distinguish the type of radiation
that will penetrate into his body and cause dam-
age. Actually, light and heat, which can be de-
tected by our senses, compose only a minor portion
of the spectrum of E-M radiation. Therefore, in
any work with radiation man has to depend upon
instruments to detect and measure the radiation.

FACTORS DETERMINING NUCLEAR INJURIES

The atomic bomb of the type used in World War
II released a portion of the tremendous forces
within the atomic nucleus by the process of fission.
The vast amount of energy released depended in

part upon the size of the bomb, and is of several
types:

1. Blast

2. Thermal

3. Initial Radiation

4. Residual Radiation

Without going into a detailed discussion of the
phenomenology of the bomb, it can be stated that
the effectiveness of this type of bomb depended
upon its size and its place of detonation. The areas
that might be affected by the blast, by the thermal
energy, and by the initial radiation were graphi-
cally demonstrated in the experiences of the two
Japanese cities over which the A-bomb was deto-
nated at about a half mile in the air. At that height,
the fireball did not touch the ground. The initial
radiation was that released directly in the process
of fission and included the release of neutrons.
From a practical standpoint, the initial radiation
did not greatly affect people who were outside the
range of the blast and heat effects.

The fission process depends upon the violent
disruption of certain atoms. These atoms break
roughly in half, and these fragments become other
elements which are radioactive. The fission prod-
ucts, then, are a whole series of radioactive ele-
ments— perhaps 30 or 40 in number. Each of these
elements goes through its decay process. These
fission products are carried up in the fireball and
cloud of the explosion. The dropping back to earth,
or descent, of these radioactive elements is known
as “fallout.” Its significance depends upon several
factors, but in general there is little fallout pro-
duced by an A-bomb. There was no significant
fallout associated with the use of A-bombs in
Japan.

The development of the H-bomb or thermonu-
clear device has changed our whole concept of de-
structive and devastating power. This type of
bomb utilizes the A-bomb as a triggering device
for the process of nuclear fusion. Theoretically,
there does not seem to be any limit to the size of
this type of weapon. This process releases energy
that produces the same effects as the A-bomb, but
in vastly greater amounts. The amount of radio-
active material produced depends upon the struc-
ture of the bomb, but may be very great. The area
of destruction from blast and heat effects depends
upon the size of the bomb, and the height at which
it is detonated. It is apparently possible to cause
almost total destruction over an area 20-40 miles
in diameter, and perhaps to cause fires over an
area 50-80 miles in diameter. If the large fireball
associated with the explosion of this type of bomb
touches the earth, tons of debris, dust and vapor-
ized earth and rock may be sucked up into the
mushroom cloud and carried up many thousands
of feet. The radioactive fission products produced
by the bomb become attached to these dust and
heavier particles. The fallout of these various
sized particles and the attached radioactive ele-

Vol. LII, No. 7

Journal of Iowa Medical Society

401

ments from this type of bomb may be of great
significance in producing casualties over large
areas.

The pattern of this fallout depends upon several
factors and can be predicted only reasonably well
at any specific time. The size of the bomb and the
height at which it is detonated are of utmost im-
portance in determining the quality and pattern
of the fallout. The Russians have recently tested
some very large weapons. Probably these were
detonated 20-40 miles above the earth, and the
fireball never touched the earth. Thus the radio-
active material was dispersed in fine particles in
the layers of space outside our usable atmosphere.
There seems to be little exchange between these
layers of space and outer atmosphere except dur-
ing violent storms over the poles. Therefore, the
radioactive material is still not falling back to the
earth, but decaying out in space. It was thought
that following the storms of winter, which might
involve the layers of space, some of the longer
half-life elements might be brought back to the
earth by spring rains.

If the fireball of an H-bomb touches the earth
and sucks up earth particles, dust and vaporized
rock, this material becomes attached to the radio-
active elements and is carried up toward 100,000
feet. The fallout from such a cloud then depends

upon the size of the particles, and the strength
and direction of the wind at various levels in the
stratosphere.

We have some available factual data on the pat-
terns of fallout. These are the data regarding
weapons testing. The monitoring of radioactivity
in the air following the Russian detonations is
done over much of the northern hemisphere. The
various monitoring stations across this country,
including the one at Iowa City, reported abrupt
increases in the amount of radioactivity at various
numbers of days after the Russian detonations. Al-
though the amount of radioactivity involved was
very small, the increase and rapid drop back
toward previous, natural levels could be detected
and studied. The elevated levels lasted for only a
few days. The elements involved are being deter-
mined, but did include Strontium 90, Iodine 131,
and Cesium 137. Each of these elements may be
ingested in various ways by human beings, and
conceivably could produce some changes.

FINDINGS IN THE MARSHALL ISLANDS

One of the most graphic and extensively-studied
episodes of fallout and its potential hazards oc-
curred during a U. S. test in 1954 in the Marshall
Islands. We detonated an H-bomb of about 12-15
megatons on a tower over Bikini. The meteorologic

ISODOSE LINES OF

ESTIMATED PATTERN OF RADIOACTIVE FALLOUT

PACIFIC PROVING GROUNDS
MARCH 1,1954

CULMULATIVE 48 HRS., WITHOUT SHIELDING

Figure I

402

Journal of Iowa Medical Society

July, 1962

conditions at the upper levels of the atmosphere
were somewhat different from what had been
anticipated, so that the cloud associated with the
bomb was carried down-wind over some occupied
islands. On Rongelap, an island 120 miles down-
wind, there were 64 natives. Approximately five
hours after the detonation, a fine snow-like ma-
terial started to settle down on the island. This
material was made up of vaporized coral rock and
contained a variety of radioactive elements. Since
the natives were outside their thatched huts much
of the time, some of this dust settled down on
their skin. The beta radiation from the radioactive
dust produced skin reactions upon the exposed
surfaces. The reaction included superficial ulcera-
tions and loss of hair. The ulcerations later healed
uneventfully. In addition to the skin reactions,
each of the 64 natives received about 175 r. to all
the tissues of his body from the bath of gamma
rays created by the layer of radioactive dust. This
type of exposure is known as total body radiation
and affects particularly the gastrointestinal tract,
the hematopoetic tissues and the gonads. The na-
tives received this dose of radiation in the 50-hour
period from the time of the start of the fallout un-
til they were evacuated from their island. Since
they had no significant protection from radiation
upon their island — no fallout shelters — they prob-
ably would have received enough radiation, if
they had not been evacuated, so that some of them
would have died. It is estimated that if these na-
tives, or any other group of human beings, re-
ceived 400 r. of total body radiation, about half of
them would die. This group of natives have been
extensively studied and carefully followed. All of
them had some changes in blood count and have
experienced some symptoms, but all have recov-
ered and a few have had children since that time.

The pattern of fallout from this test detonation
on Bikini was quite accurately estimated, and is
shown in Figure 1.* The isodose lines show the
areas of various dose levels. The elongated oval
shape is produced by the prevailing winds at
various heights blowing at that particular time.
Dose levels that might well have caused death if
there had been no evacuation or shielding existed
over several thousand square miles.

IOWA'S PROBLEM

This type of information has been applied to the
spread of fallout from likely target sites across
our country. Many assumptions have to be made
in this type of prediction. In all-out nuclear war,
it would have to be assumed that most of the tar-
get areas would be completely destroyed and that
most of the occupants of those cities and areas
would be killed, regardless of the type of shelters

* Cronkite, E. P., Bond, V. P., and Dunham, C. L., eds:
Some Effects of Ionizing Radiation on Human Beings: a
Report on the Marshallese and Americans Accidentally Ex-
posed to Radiation from Fallout and a Discussion of Radia-
tion Injury in the Human Being. Washington D. C., U. S.
Atomic Energy Commission, July, 1956.

available. In these areas, only the deepest type of
tunnel or underground cavern would provide par-
tial protection from the blast effect and might well
fail to provide protection from the extensive fire
that would follow. However, outside the target
areas fallout could be the most damaging agent
and could produce many casualties if not detected
and protected against. Figure 2 illustrates the
possible extent of fallout across our state from a
detonation over the Omaha area, the location of
Strategic Air Command headquarters and several
missile bases. Again, many assumptions are neces-
sary in making even this rough estimate, but it
is conceivable that this could be the situation.
Knowledge of the size and shape of the area of
fallout and of the dose rates would be essential in
any organized attempt to advise people in the
involved area about the best measures to take to
increase their chances for survival.

There are two general factors that one must con-
sider in trying to reduce the effects of fallout.
These are the rate of decay of the radioactive ma-
terial and the protective shielding. It is estimated
that the mixture of fission products decays accord-
ing to the scheme shown in Table 2.

TABLE 2

DECAY OF FISSION PRODUCTS

Time After H Hour

Dose Rate

H Hour

1,000 r./hr.

H + 7 hrs.

100

H + 49 hrs.

H + 14 days

If a person can be protected or shielded from the
radiation for even a two-day period, the amount
of radiation will have fallen by a factor of 100. Of
course, the dose rate at the start, or just after
maximum contamination, is the determining value.
If this were ten times that shown in the chart, the

Mark Your Calendar
1963 ANNUAL MEETING
IOWA MEDICAL SOCIETY
April 21-24
Des Moines

Vol. LII, No. 7

Journal of Iowa Medical Society

403

dose rate after two days would still be relatively
high, and cumulative exposure of over two hours
would produce serious symptoms and perhaps per-
manent damage.

In addition to the factor of decay, the factor of
shielding is important in reducing the amount of
radiation that reaches a person. Here again the
original dose rate is the determining value. Vari-
ous thicknesses of material such as concrete or
packed earth will reduce the amount of radiation
by a certain factor. A home shelter in a basement
may reduce the amount of radiation by a factor
of 50, whereas a deep community shelter might
reduce the radiation by a factor of several hun-
dred.

CONCLUSION

In consideration of this information, it seems
apparent to me that under certain circumstances,
in certain locations, fallout shelters might be very
valuable and make the difference between life and
death for the occupants. However, it should be not-
ed that our present estimates of the value of fall-
out shelters are predicated on our current under-
standing of technologic developments, and that
within 5 or 10 more years they may again need to
be completely revised.

We have considered only the radiation aspects
of nuclear war and barely mentioned the other
devastating effects of nuclear weapons. We have
not mentioned the possible use of other classes of
damaging and lethal agents such as might be ex-
pected in bacteriologic and chemical warfare. We
have only alluded to the complete disruption of
our society and the complex organizations that
produce and distribute the goods and services we
now take for granted. We have not considered the
long-range effects of the long-half-life radioiso-
topes.

If one recognizes the magnitude of the death
rate, of the damage, of the disruption of our so-
ciety, as we now know it, then the role of civil
defense and the value of shelters can be more ac-
curately evaluated.

Personally, I am developing a profound awe and
horror of the catastrophic nature of all-out nuclear
war. I feel that a civil defense effort can be of some
value in helping to improve the limited chances of
survival for the fortunate who escape the immedi-
ate effects of the nuclear weapons. I still believe
that the human race will go on in spite of an all-
out war, but it will have a very different existence
from that which we now enjoy.

"Educated Guess'Fallout Pattern

Figures From White House Conference on
Fallout Protection, Jan. 25, I960

Figure 2

Radiation Pathology

HAROLD E. RESINGER, M.D.

Lexington, Kentucky

The effects of the explosion of an atomic or hy-
drogen weapon can be divided into two broad cate-
gories, viz: the direct and the indirect effects. The
direct effects include injuries to the body caused
by the sudden changes in atmospheric pressure,
flash burns due to the intense heat that is produced
for a fraction of second at the instant of detonation
and, finally, the effects of subsequent exposure to
ionizing radiation resulting from the blast. It has
been observed that the indirect effects of such an
explosion, which will be discussed later, account
for more deaths, and more violent deaths, than do
the direct effects alone.

DIRECT INJURIES

Contrary to what is generally believed, the di-
rect injuries from the blast itself are slight as com-
pared with those produced by the blasts of conven-
tional high explosives. The detonation of a con-
ventional explosive renders a hammerlike blow
by means of a sudden change in atmospheric pres-
sure, whereas the blast from an atom bomb ex-
plosion has been likened to a sudden violent gust
of air which lasts for a brief but appreciable period
of time. It would appear, then, that the peak
change in atmospheric pressure is achieved rapid-
ly in cases of blasts due to conventional high ex-
plosives, but more slowly and gradually in those
due to the atom bomb. This difference, then, would
explain the much lower incidence of ruptured ear-
drum in persons exposed to the atomic bomb blasts
in Japan, as compared to the known relatively-
high incidence of ruptured eardrum in persons
who have been in close proximity to conventional
blasts. It was found in the Nagasaki and Hiroshima
blasts that the incidence of ruptured eardrums,
even in those who were within 1,000 yards of the
hypocenter (the point on the ground directly be-
neath the blast) was only one to two per cent.

During the Japanese explosions the blast hurled
a few persons forcibly against solid objects. This
phenomenon, however, must be considered as an

Dr. Resinger, formerly associate pathologist at Mercy Hos-
pital, Des Moines, made this presentation at the Conference
on Medical Civil Defense held at Oelwein on November 9,
1961. He is now Director of Laboratories, Good Samaritan
Hospital, Lexington, Kentucky.

indirect effect of the blast, since the blast, per se,
did not cause the resulting injuries even though it
predisposed the victims to them.

The “flash” burns resulting from an atomic ex-
plosion were due to exposure to the radiant energy
produced by the bomb, which like other forms of
radiant energy, travels in straight lines. For this
reason, only those body surfaces which were di-
rectly exposed to the radiation suffered burns, and
intervening objects cast “shadows.” The radiant
energy of the atom bomb had a spectrum resem-
bling that of the sun and existed only for a brief
interval. The magnitude of this energy was such
as to cause crazing and fragmentation of the sur-
face of granite within several hundred yards of
the hypocenter. This effect was due to unequal ex-
pansion of the granite, and it has been estimated
that a temperature of at least 3,600° F. is necessary
to produce this effect.

Since radiant energy varies inversely as the
square of the distance, it will be seen that the dis-
tance from the point of explosion will be of prime
significance insofar as the degree of tissue damage
is concerned. Clothing will offer some protection
from the flash burns beyond a certain point, de-
pending on the energy released by the explosion,
but dark areas in patterned cloth absorb more
heat than light areas do, and in some cases the
same pattern is seen in skin burns as was present
in the cloth immediately overlying the skin. The
skin changes due to the flash burns are variable,
depending on the distance from the explosion,
and the quality and quantity of protection pro-
vided by intervening objects, including clothing.
In the Japanese bombings, burns were fatal in
95 per cent of individuals within 1,200 yards of the
hypocenter. The severe burns produced complete
dermal destruction. Less-severe burns ranged from
second degree to erythema, depigmentation and, in
those farthest from the blast, intense pigmentation
resembling severe sunburn.

The damage produced by ionizing radiation in
an atomic blast has two different soui’ces, viz:
exposure to those ionizing radiations emitted at
the instant of detonation and for a few seconds
thereafter, and exposure to those radiations re-
sulting from fallout. At the instant of detonation,
gamma rays, neutrons, beta particles and alpha
particles are released. Also some radioactive fis-
sion products may be emitted, and possibly some
of the unexploded radioactive substance of the
bomb itself. Here, again, distance and shielding

404

Vol. LII, No. 7

Journal of Iowa Medical Society

405

are of prime importance, just as they are with
the flash burns. Alpha and beta particles travel
only short distances in air and can be disregarded.
Also, because of the violent updraft of air caused
by the intense heat of the explosion, most of the
fission products are swept into the stratosphere.

The amount of neutron and gamma radiation,
however, is very important. Neutrons can be
projected for considerable distances in air and
have an ionizing potential several times greater
than gamma rays since they can induce radioac-
tivity either in the air or in the tissues through
which they pass. Gamma rays, even though their
ionizing potential is less than that of neutrons,
have a great ionizing ability, and are especially
damaging because of the large quantities of such
radiation emitted at the time of explosion. The
gamma rays with shorter wave-length have the
greatest penetrating power in tissue, and may pass
completely through the body, whereas those of
longer wave length may be absorbed in air before
reaching the body, or may be absorbed in super-
ficial tissues. Gamma rays, in passing through air
or tissue, follow devious paths as a result of colli-
sions with subatomic particles. During such colli-
sions, their wave-length is modified by the “Comp-
ton effect,” so that the actual quantity of energy
absorbed by the body can never be determined
with any accuracy.

The period of time over which a given amount
of radiation is absorbed is especially important.
Six hundred roentgens of total body irradiation
administered within a few seconds, as in an atomic
blast, constitutes a fatal dose, whereas a similar
dose administered fractionally to the total body
over a period of days or weeks may or may not be
fatal, depending upon the individual’s tolerance to
radiation, upon the size of the fractional doses and
upon the total period of time over which the total
dose is administered. The biologic effects of radia-
tion are further modified, both quantitatively and
qualitatively, by shielding. The less the area of the
body that is exposed to radiation, the greater are
the chances of survival. By the same token, protec-
tion of such important structures as the bone
marrow offers a greater chance of survival, even
if only a portion of the active marrow is afforded
such protection.

SECONDARY EFFECTS

As previously mentioned, the secondary effects
of the atomic explosion probably account for more
deaths than the primary effects. Falling debris may
kill instantly or may incapacitate or trap victims
so that they are consumed in the widespread fires
which follow such an explosion. Those individuals
close to the point of detonation are most likely to
suffer such a fate. That this is true is shown by the
fact that only 4.5 per cent of those surviving the
Hiroshima blast showed fractures.

Secondary infection of burns was extensive in
the Japanese, and accounted for many deaths. Re-

gardless of the usual cleanliness of a population,
a catastrophe such as an atomic explosion is so
disruptive to sanitation and medical facilities that
many cases of burn infection may be expected.

Past opinion regarding the biologic changes due
to radiation exposure was that the basic alteration
was of a physical nature and, for this reason, that
one could pinpoint the area of damage within a
cell and determine the structure sensitive to radia-
tion. It is now felt that the biologic alteration is of
a chemical rather than a physical nature, and that
the location of damage is not nearly so specific as
formerly thought. It appears that the basic changes
occur in the water of the cells — in the solvent for
the dissolved substances. Radiation of water pro-
duces un-ionized H and OH radicals which are
highly reactive and which rapidly interact among
themselves or with dissolved substances, depend-
ing on which type of molecule is closer. Therefore,
dissolved enzymes are more likely to be altered in
concentrated solution than in diluted solution, be-
cause in the former there is a closer spatial rela-
tionship between the H and OH radicals and the
enzyme molecules. Such an interaction can be ex-
pected to cause either reduction or oxidation of the
enzyme molecules. If the H and OH radicals react
with each other, they probably produce — among
other things — hydrogen peroxide, which is an oxi-
dizing agent. It is known that some of these inter-
actions are toxic or lethal to the involved cell.

It has been found that protection of cells from
such toxic or lethal changes is afforded by the
presence of compounds which have a greater
affinity for the un-ionized H and OH radicals. Sul-
fur-containing compounds have such an affinity.
Cysteine and glutathione, if given in advance of
irradiation, will offer such protection.

Protection is also afforded by a hypoxic condi-
tion of the irradiated animal, but at present those
substances producing sufficient hypoxia are just as
dangerous as is the radiation.

Cell changes produce either death or decreased
function, inability to reproduce, or mutation. Those
cells which reproduce most rapidly are usually
most affected. In the order of decreasing sensitivity
are spermatogonia, lymphocytes, erythroblasts,
other hematopoietic bone-marrow cells, small in-
testinal mucosal cells, gastric mucosal cells, colonic
mucosal cells, skin, central nervous tissue, muscle,
bone and collagen. Recovery of testicular function
has been seen to occur following radiation doses of
less than 800 r., but as little as 10 r. may produce
noticeable changes. Lymphocytic tissue may show
a spectrum of changes ranging from cessation of
mitotic activity to a marked atrophy, but usually
will regenerate slowly if the patient survives.
Cessation of red-cell production by the bone mar-
row is not readily apparent from examination of
peripheral blood because of the 120-day life span
of normal red cells. However, new red cell pro-
duction is diminished after irradiation, and a
gradual decrease in hematocrit and hemoglobin

406

Journal of Iowa Medical Society

will be noted as worn-out red cells are destroyed.
Deficiencies in white cells and platelets are appar-
ent earlier because of the short life span of these
structures, and even though their precursor cells
are less sensitive to irradiation than are the pre-
cursors of red cells, neutropenia and thrombo-
cytopenia, with their secondary changes, will be
noted much earlier than anemia. It is unlikely that
recovery will occur following total body doses of
800 r. or more. However, chances for recovery are
far greater if some bone marrow has been spared
from irradiation. The effects on small-intestinal
mucosa, again, depend on the absorbed radiation
dose, and they range from suppression of mitotic
activity to a nearly complete denudation of the
mucosa. In the latter instance, marked fluid and
electrolyte imbalances supervene, as well as hem-
orrhage resulting from associated thrombocyto-
penia. If the patient survives, regeneration of the
mucosa will begin in the crypts of Lieberkuhn, and
complete regeneration will have occurred by about
the twelfth post-irradiation day.

Heavy radiation doses cause peripheral-blood
neutrophil counts to reach their lowest levels at

The Management of

PAUL FROM, M.D.

Des Moines

The first atomic bomb was set off under experi-
mental conditions from a tower near Alamagordo,
New Mexico, on July 16, 1945. The second and
third bombs were dropped from B-29 bombers
on August 6 and August 9, 1945. The second bomb
instantly and completely devastated four square
miles of Hiroshima, and the third bomb totally
destroyed 1.5 square miles of Nagasaki. In Hiro-
shima, 66,000 people were dead or missing, and
69,000 were injured, and in Nagasaki, 39,000 were
killed and 25,000 injured. Since that time, 80 or
more thermonuclear devices have been detonated,
albeit none in true anger. The only information we
have as to the effects of these devices has come
from studies of the two Japanese cities, from ex-
perimentation following various trial detonations,
including fallout contamination after a high-yield
test explosion at Bikini Atoll on March 1, 1954, and
from a rare accident in the handling of fissionable
material.

The grave uncertainties in today’s international

Dr. From, a Des Moines internist, made this presentation at
a conference on medical civil defense in Oelwein on Novem-
ber 9, 1961.

July, 1962

about two weeks, whereas lesser doses do not pro-
duce their maximal neutrophil effects for five to
six weeks. The peripheral white blood cell count
may not return to normal until a year has elapsed.
The platelet count may increase during the first 48
hours, but on the fourth or fifth day it begins to
fall, and it reaches its lowest level at about four
weeks. It is at that time that the danger from hem-
orrhage is most serious. Although the platelet
count may not return to normal for as long as
two years, sufficient recovery will have occurred
within six to eight weeks to produce platelet levels
above the range at which spontaneous hemorrhage
occurs.

Probably the greatest danger in the post-irra-
diation period is infection. Neutropenia, poor anti-
body production due to damage to the reticulo-
endothelial system, impairment of the motility and
phagocytizing abilities of phagocytes, and areas of
hemorrhage which tend to become infected — all
these contribute to the patient’s marked vulnera-
bility in regard to infection. Even normally sap-
rophytic organisms may become pathogenic under
such conditions.

Radiation Casualties

situation have imposed a unique, unprecedented-
ly heavy responsibility on the American doctor.
He is now being called upon by planning groups
throughout the nation to assist in making realistic
preparations for possible future hydrogen bombing
of our cities. Sir Charles Snow, in an address on
“The Moral Un-Neutrality of Science,” has pointed
out that the creation and stockpiling of nuclear
weapons means that inevitably — sooner or later —
some of them are going to go off. It seems, there-
fore, that a brief discussion of the hazards that
might be encountered is sure to be of value.

ESTIMATES OF PROBABLE RESULTS ARE UNRELIABLE

A realistic estimate of the number of casualties
which might occur is impossible because the re-
sults of any bombing would be dependent upon
many factors, such as type of burst, type of con-
struction in the city, season of the year, density
of the population, time of day the detonation oc-
curs, and magnitude of the detonation.

Our previous information was based on 20-kilo-
ton explosions (20,000 tons) in Japan. As we know,
Russia recently exploded a device rated at a yield
of 60 megatons (60 million tons) — nearly 3,000
times more powerful than those exploded in Japan.
In Japan we produced an atomic (fission) explo-
sion; now we must think in terms of hydrogen
(fission and fusion) explosions. It is thought that

Vol. LII, No. 7

Journal of Iowa Medical Society

407

these tremendous-yield devices are not militarily
feasible, but are used only for propaganda. Even
so, a militarily feasible yield would be in the range
of 20 to 25 megatons.

A thermonuclear device can cause casualties by
three principal means: blast, thermal burns, and
radioactivity. Each of these phenomena is distinct,
and could be considered separately. There are
three methods of detonation of a device— in the
air, on the ground, or in water.

TYPES OF DAMAGE

Although it is thought that, for all practical
purposes, one need not consider any survival in
the area of the blast, and with extremely high-
yield detonations this area could encompass hun-
dreds of miles, a brief review of the types of cas-
ualties resulting from the bombing of Hiroshima
and Nagasaki will be of interest.

1. Blast Effects. A. Direct. Casualties of this sort
result from the sudden increase in pressure which
enters the body through the mouth, nose, ears, and
anus, and which inflicts trauma to the lungs, rec-
tum, eardrums and other organs. In Japan, direct
blast casualties were limited to fewer than 200
ruptured eardrums. Japanese medical observers
could not find any patients with direct damage to
the internal organs caused by the blast. Necropsies
of the early cases showed no evidence of blast
damage to the lungs. Many persons were said to
have lost consciousness temporarily, with no his-
tory of direct trauma to the head.

B. Indirect. These effects are caused by flying
debris, timber, and glass. As in conventional bomb-
ing, these results are much more important, but
exactly how much of a total mortality in a bomb-
ing is caused by the traumatic factor can never be
known, because soon after a blast the area will be
swept by fire, and anyone unable to get away will
undoubtedly burn to death.

2. Biirns. A. Flame Burns. These are sustained
as a result of secondary fire produced by short
circuits, exploding gas mains, etc. Again, these
burns are rare, for it takes time for fire to spread,
and those unable to get away are burned to death.

B. Flash Burns. Such injuries are caused by the
intense heat that radiates from the ball of fire.
The thermal energy causing these burns probably
lasts only three seconds. With high-yield hydrogen
explosions, this type of burn can occur 17 to 30
miles from the point of detonation.

C. Effects of Radiation Energy on the Eye. Al-
most all patients in Japan had temporary ambly-
opia that lasted for an average of five minutes.
This is caused by light of sufficient intensity to
wash-out the visual purple in the retina, and blind-
ness ensues until the body can re-supply the visual
purple. Because of the focusing action of the lens,
enough energy can be collected to produce a burn
of the retina at such a distance from the explo-
sion that the thermal radiation intensity is too
small to produce a skin burn.

Cataracts can develop long after exposure to
radiation, especially to neutrons.

D. Keloid Changes. These were frequent in Ja-
pan, and were thought to have been aggravated by
infection and malnutrition. These keloids tended
to disappear in the course of time.

E. Pigmentation and Depigmentation. These
changes are due to ultraviolet rays. The area of
increased pigmentation, surrounded by an area of
less than normal pigmentation, began to subside in
four months, but in some cases it persisted. Cloth-
ing protected the skin from these changes.

3. Radiation Injury. We are concerned mainly
with the effects of gamma rays and neutrons, since
these radiations are the ones which have the abil-
ity to penetrate into or through the body. The
ionizing radiation received from a bomb-burst is
almost instantaneous in character. A dose of 400 r.
over the total body surface is sufficient to cause
death in about half the exposed population. The
LD 100 dose is about 600 r.

The radiations from the bomb consist of prompt
and delayed radiations. A. Prompt radiations come
from the chain-reaction itself and last only a few
millionths of a second. They consist of hard, pene-
trating gamma rays and neutrons.

B. Delayed radiations consist of gamma rays
and beta particles emitted by the fission products
immediately after the explosion. Fission products
are the lighter elements formed by the splitting
of the plutonium or uranium 235 in the bomb.
The atoms split in a number of different ways, so
that a single explosion produces nearly 160 types
of fission products (strontium, cesium, iodine, etc.),
all of which are radioactive.

Besides forming fission-products, the nuclear
chain reaction creates tremendous temperatures,
vaporizing all the bomb components into an incan-
descent mass of gas. This mass, or ball of fire, ex-
pands rapidly until it is less dense than the sur-
rounding air, and then it rises rapidly. Nearly all
the fission products are in or around the ball of
fire, and therefore, ascend with the cloud. The
cloud ascends at the rate of about 10,000 feet a
minute.

C. Residual radiation is emitted from fission
products falling out of the cloud, or remaining on
the surface following detonation. As the winds
aloft carry the cloud, this residual radiation may
fall out hundreds of miles from the site of detona-
tion.

What are the effects of radiation? Epilation was
frequently observed in people who had been close
to the bombs in Japan, and who survived for more
than two weeks. This falling-out of hair persisted
from the thirteenth to the twentieth or twenty-
seventh day. In no case was epilation permanent,
and hair returned within three months.

Nausea and vomiting can occur within 30 min-
utes to 24 hours. A bloody diarrhea may develop
within the first few days.

Radiation effects on the testes are discernible
within four days, and can persist indefinitely. The

408

Journal of Iowa Medical Society

July, 1962

ovaries show less striking changes than the testes.
Amenorrhea was common for three to four months
after the bombing, but within one year the menses
in all people studied were normal.

Purpura was almost always seen in people dying
in the third to sixth weeks. Puipura and fever oc-
curred almost simultaneously, reaching a peak in
16 to 22 days after exposures. At that time, there
was an increased tendency to bleed from lacera-
tions, fractures and burns. Healing of wounds was
delayed, and if radiation sickness developed,
wound healing stopped. Bleeding could occur from
nose, gingivae, lungs, urinary tract, and rectum.

The clinical syndromes in radiation sickness
were of two types. 1. Patients who died within the
first two weeks showed no epilation and no pur-
pura, but they experienced nausea and vomiting,
then anorexia, malaise, diarrhea, thirst, fever,
delirium, and death. Temperature elevation began
between the third and seventh day, and remained
constantly elevated up to the time of death.

2. Patients who died during the third to sixth
weeks showed epilation and bone-marrow hypo-
plasia, in most instances. Necrotizing lesions were
found in the gums, lungs and gastrointestinal
tracts. Nausea and vomiting and malaise occurred
early, and then there was clinical improvement
until the fourteenth day, when epilation began,
followed by malaise and fever. Sore throats de-
veloped, as did a bloody diarrhea and severe weak-
ness due to anemia. Petechiae developed. The clin-
ical picture was that of an aplastic anemia, and
even though bone-marrow function might recover,
many Japanese later died of secondary infections
such as lung abscess or tuberculosis.

On the basis of the foregoing, how can we pre-
pare ourselves to handle the terrific number of
casualties resulting from a nuclear explosion?

We know that a prime military target is rela-
tively near us — Offutt Air Force Base, the head-
quarters of the Strategic Air Command. The at-
tack could take the form of an air blast, but we
could expect Russia to detonate a device as a
ground blast, since SAC is mainly underground,
and the enemy would attempt to destroy the un-
derground facilities. From a ground-blast, residual
radiation is greater. One must always remember
that the rocket might miss its mark, and place us
in the blast area, or that certain areas not consid-
ered military targets might be destroyed simply
for the sake of a demoralizing effect.

In such an event, of course, all permanent fa-
cilities in the blast area will have vanished, and
all trained personnel and supplies will have been
destroyed. Subsequently, because of radiation ef-
fects, the area will be inaccessible for 14 days or
more, and thus anyone living through one blast
and not protected from radiation will undoubtedly
become a case of radiation sickness. It is not im-
possible that two weeks after a blast the undam-
aged areas will be commandeered for the treat-
ment of casualties flown from the blast area.

However, since little will be left of a blast area,

we need concern ourselves but little with these
problems. What, then, about protection of areas
in the fallout pattern?

We know from studies at Bikini that the fall-
out pattern from a bomb-burst follows roughly a
cigar-shaped pattern about the blast area, the main
direction depending upon the direction of the
winds aloft. The area of fallout may extend for
hundreds of miles.

PROTECTION AGAINST FALLOUT

Measures to be taken to protect against fallout
are passive or active. Passive protection implies
remaining in the contaminated area but taking all
possible shelter, particularly from the gamma rays
emitted by the fission products in the fallout. One
very important factor to keep in mind is that these
rays can travel only in a straight line, and can be
absorbed or stopped by mass. Even the basement of
a frame house can attenuate the radiation by a
factor of 10, and greater reduction is possible in
a large building or in a shelter covered by several
feet of earth.

Active protection, implying evacuation to a safe
area, is not feasible. A city could not be evacuated
quickly enough, and because of a change of wind
patterns a so-called safe area might be highly un-
safe by the time a populace arrived there. How-
ever, there is one active protective measure which
has great value, and that is decontamination after
the fallout has settled. Steps must be taken in
any contaminated area to decrease the amount of
fallout in critical regions — e.g., roofs of houses, and
streets. These procedures are hazardous, since
they involve exposure of the operating personnel
to fairly high levels of radiation.

Let us discuss some measures of passive pro-
tection in fallout shelters. A ventilation system
with filters is desirable, but not mandatory. Air
coming through cracks or through the walls would
be sufficient to sustain life, and although fallout
may enter the same way, breathing this in would
not constitute a serious hazard. Home-type base-
ment shelters are adequate, but should be special-
ly constructed so that the ceiling could support
the weight of the collapsed superstructure if such
a collapse should eventually take place. Supplies
of food and water for 14 days should be on hand,
and they should be covered to protect them from
the fallout. The water must be fresh.

A gasoline generator for power should be avail-
able.

A battery-operated radio for “Conelrad” fre-
quencies is imperative.

Provision must have been made for warmth,
and for disposal of waste materials.

Two and one half to three gallons of water per
person per week will be needed in the shelter. If
no one has thought to store water, safe water can
be found in the home in the hot water tank and in
the toilet.

Only a clean, or decontaminated, person is al-
lowed in the shelter. If not clean, the clothing

Vol. LI I, No. 7

Journal of Iowa Medical Society

409

should be left outside the shelter. This should not
be a problem in most parts of this state since, for
example, about one and one-half to two hours
would elapse before fallout from a blast at Omaha
would occur in Des Moines, and most people would
have had time to get into their shelters.

Suitable instruments are needed for detecting
the level of nuclear radiation, and one must un-
derstand the use of the instrument. The first sur-
veys over the area will most likely be made by
plane or helicopter outfitted with survey meters.
Ground observation can be made later, but per-
sonnel making these surveys must be protected
with individual monitors.

DECONTAMINATION

Once the radiation level has been found toler-
able, decontamination procedures are started.
These have as their goal the removal and disposal
of contaminants. Covering the contaminant with
soil is an excellent way to accomplish both these
goals. Burning, burying, washing with water, or
using a vacuum cleaner are other methods of de-
contamination. Decontamination personnel must
wear clothing that has been adapted to prevent
dust or water from reaching the skin.

What of the problems connected with water?
Rivers, storage tanks, etc., are all subject to fall-
out. However, because of dilution by flow, and be-
cause of natural decay, water in a city system is
safe to use. Well water is safe, for the soil will
filter out contamination. Any water should be safe
after several days. Distilling water will make it
safe, but boiling alone is of no value in decontam-
inating it.

SUMMARY

What then, in summary, must we as doctors ad-
vise in care of a radiological attack? Everyone
must get into a shelter immediately and stay there
until it is safe to be out — a matter of 14 days or
so — and this includes the doctor himself.

What can the hospital do to handle the situa-
tions resulting from a radiological problem? Doc-
tors and other personnel very likely will not be
available during the critical fallout period. Plans
must be made for the stocking of sufficient food
and water to carry the hospital through the first
week or so, and plans must be made for decon-
tamination of anyone coming into the hospital
area. Plans are needed for determining who will
benefit from the meager supply of food and drugs
available. Emergency power equipment must be
adequate and available.

If radiation-syndrome casualties are found, how
can they be handled? One must ascertain, if pos-
sible, whether the patient has experienced a prob-
ably lethal dose of radiation. This is done by refer-
ring to the time of onset of symptoms and signs.
Since we would be woefully short of supplies, if
a person has had a probably lethal exposure, treat-
ment of an active nature must not be wasted on
him. If survival appears possible, therapy then re-

volves about adequate fluids, antibiotics, whole
blood transfusions, and adequate vitamin intake.
Supportive therapy for diarrhea and infections is
indicated.

After all else, plans must be formulated for dis-
posal of the dead, which probably will be a not
insignificant problem.

The immediate problem when you are faced
with a nuclear explosion or severe fallout is sur-
vival— your personal survival. Without this, you
are not going to be available to do your job later.
Above all, it is important that as many human be-
ings as possible really grasp our present predica-
ment. President Kennedy stated it well, in an ad-
dress to the United Nations: “Today, every in-
habitant of this planet must contemplate the day
when it may no longer be habitable. Every man,
woman, and child lives under a nuclear sword of
Damocles, hanging by the slenderest of threads,
capable of being cut at any moment by accident,
miscalculation, or madness. The weapons of war
must be abolished before they abolish us.”

Physician Population Boosted by 4,500

The physician population of the United States
and its possessions increased by about 4,500 in
1961, the American Medical Association reported
recently in a compilation of medical licensure sta-
tistics for the year.

The report showed that a total of 8,023 first
licenses to practice medicine and surgery were
issued in 1961. Subtraction of approximately 3,500
— the physicians who died during the year — leaves
a physician population increase of about 4,500.
The 1960 net gain was 4,330.

Of 8,714 applicants for licensure by written ex-
amination, 7,650 passed and 1,064 (12.2 per cent)
failed. However, the rate of failure in approved
medical schools was only 2.8 per cent. Twenty-six
approved schools had no failures among their
graduates. The greatest number of graduates from
any one school to be examined was 214 from the
University of Tennessee College of Medicine.

Statistics also were reported by the Educational
Council for Foreign Medical Graduates, founded
in 1957 to certify that foreign-trained physicians
entering the United States had an education equiv-
alent to that of graduates of approved medical
schools in this country. The Council, which has
held eight qualification examinations for foreign
medical graduates, said the “net effect” of the
ECFMG certification plan has been not to restrict
but rather to increase both the number and the
Quality of foreign medical graduates coming to
the United States for graduate training in hos-
pitals.

In 1961, more than 3,600 foreign medical gradu-
ates were qualified directly from abroad by the
ECFMG. This number is now greater than that
of the graduates taking the examinations in the
United States.

Fire Safety in the Hospital

ED. J. HERRON
State Fire Marshall

Fire safety is paramount in the day-to-day oper-
ation of hospitals, and it is of major importance
to all fire departments. The fire service spends
many hours in “pre-planning sessions” which are
devoted to preparation for all possible situations
that could occur in a hospital fire.

In addition to the pre-planning for hospital-fire
fighting that the fire control officers do, the fire
prevention personnel devote a great deal of time
to making inspections. Copies of their reports are
given to the hospital administrators, together with
recommendations that will provide increased
safety for life and property. These same reports
and recommendations are channeled to the fire
officers within the fire department so they will
be apprised of the current situation at all times.
Additional reports are reviewed by the chief of-
ficers as a result of conferences between fire-pre-
vention personnel and city officials such as the
water commissioner, streets commissioner, police
commissioner and the public utilities executives.
All of this preparation is necessary so there will
be maximum efficiency in fire department opera-
tion, and a minimum of unexpected situations in
case a hospital fire should occur.

Such efforts on the part of the fire department,
in cooperation with the hospital administrators,
have resulted in a high degree of fire safety in our
hospitals. However, from time to time, tragedies
occur that focus national attention on our hos-
pitals. Within the past few months, two hospital
fires have occurred in which several patients have
lost their lives. The Hartford, Connecticut, fire
started in a hospital incinerator chute, and the
chain of events following its discovery let it de-
velop into a serious fire that broke out into the
corridor on the ninth floor, where the ceiling and
wall-finish materials were combustible. The intense
fire was confined to the ninth floor, but caused
the deaths of several patients.

During the 1960 Christmas holidays, flammable
decorations in the lower lobby of a Minneapolis
hospital became ignited. Then, because the fire
doors protecting the stairways were blocked open,
and because there was a delay in summoning the
fire department, several lives were lost.

COMMON FAULTS OF HOSPITALS

Reports following investigations of hospital fires
throughout the country during the past few years
have brought out several shortcomings that seem
to be common to all hospitals. First, there is a
widespread lack of emergency plans for the hos-
pital personnel, and many of the hospitals that
do have plans have not kept them up to date or
practiced the procedures regularly. The conse-
quent lack of familiarity with emergency pro-
cedures is almost certain to result in costly mis-
takes when serious emergencies occur.

Second, most modern hospitals are of fire-re-
sistive construction and this fact lulls the admin-
istrator and the staff into a false sense of security.
Most of our tragic hospital fires in recent years
have resulted in very little damage to the struc-
tures themselves. The fire was confined to the
interior contents and the finish materials, which
were combustible, but patients have nevertheless
been burned or have been overcome by toxic
fumes.

Third, investigation following the fire in nearly
all cases has revealed there was a delay in calling
the fire department. The desire of the staff to pre-
vent excitement or panic has resulted in a time
lag that allowed the fire to burn for several min-
utes after discovery before the fire department
was summoned. In the recent Hartford, Connecti-
cut, fire, approximately 20 minutes elapsed be-
tween the discovery of the fire and the calling of
the fire department.

Fourth, the professional staff of doctors and
nurses performs magnificently under fire condi-
tions, and without doubt, the doctors and nurses
have saved many lives. Reports have indicated,
however, that if these professional people had had
immediate assistance from the fire departments,
and if the hospital maintenance staff had been
trained to relieve the doctors and nurses of fire-
control and evacuation work, the loss of life
could have been reduced.

STANDARDS FOR FIRE SAFETY

The evaluation of reports compiled as a result
of investigations of hospital fires in recent years
has enabled the fire authorities to recommend sev-
eral standards for fire safety in our hospitals. First,
every hospital should formulate an emergency
plan, specifying the duties of each employee. The
plan should be kept current and reviewed regu-

410

Vol. LII, No. 7

Journal of Iowa Medical Society

411

larly at employee meetings. Where practical, the
parts of the plan that can be practiced should be
incorporated into the regular drills.

Second, hospital construction, interior appoint-
ments and finishes, and exit facilities should be
reviewed by the hospital administrator and fire
officials. Special fire-protection devices such as
door closers, fire extinguishers, fire-alarm systems
and sprinkler systems should be made parts of
any new construction or remodeling plans.

Third, there should be frequent and regular in-
spections to check for fire hazards — especially
those that involve equipment, storage rooms,
maintenance shops, laundries, kitchens, heating
and air conditioning units, storage of flammable
liquids and gas — along with regular checks on the
condition of fire extinguishers, emergency lights,
alarm systems and exits. These inspections should
be reported in detail, and conditions needing cor-
rection should be taken care of immediately by
the maintenance staff.

Fourth, semi-annual or annual meetings should
be scheduled for the discussion of the over-all
fire-safety program and the fire potential of the
hospital, and for a review of reports made by fire
inspectors. Members of the fire department, doc-
tors, nurses, maintenance staff, and members of
the hospital board should be in attendance at
these safety meetings. All groups should be rep-
resented at the meetings so that no single group
will be working at cross purposes with another
group in their joint attempts to provide fire safety.
Compliance with these basic standards will help
a great deal in preventing loss of life from fires
in our hospitals.

PREPARATIONS FOR NUCLEAR ATTACK

Hospitals, however, along with industry, busi-
ness and other groups must, for the first time,
give some thought to the creation of safeguards in
case of a nuclear attack. In the event of a nuclear
war, serious fire problems would develop in areas
extending for many miles around “ground zero,”
the site of the detonation. There is no way of
knowing the exact size of the nuclear device an
enemy might use, but our military people say the
10 and 20 megaton devices are very practical from
the military standpoint. A megaton is the equiva-
lent of one million tons of TNT.

Three basic problems would confront the hos-
pital and fire authorities in case a 10- or 20-ton
nuclear device were dropped in the area where
the hospital is located. These problems are the
effect of, first, the blast wave, second, the thermal
wave, third, the radioactive fallout. All of these
would follow the detonation. The blast wave and
the thermal wave would be close together, fol-
lowed by a delay of approximately a half hour
before the arrival of radioactive fallout. The blast
wave and thermal wave would be circular in cov-
erage, extending outward from ground zero for 20

to 30 miles in case of a surface burst. The radio-
active fallout would be elliptical in shape, with
the fallout following the direction of the prevail-
ing winds. This fallout would occur in an area
several miles across, but it could extend for many
miles in length, and for many hours the radiation
in the elliptical area would be above the safe
level for unprotected human beings. Results of
our nuclear tests have indicated that there would
be complete destruction in an area eight to 10
miles in diameter, but that in the rest of the area
which would feel the effects of the blast wave and
thermal wave along with the fallout pattern, large
numbers of people could survive, provided that
emergency plans were available and were put in-
to action.

A study of the fire-bombing attacks on the cities
of Germany and the atomic-burning of the cities
in Japan in World War II has indicated that the
degree of success in containing mass fires is based
on the preparation that has been undertaken to
reduce the fire potential.

The fire safety program for hospitals should in-
clude planning for nuclear-device bombing, as well
as for ordinary fire hazards. The ordinary plans,
indeed, can well be the basis for protection against
a nuclear-device attack. However, because of the
magnitude of the fire problem that would be creat-
ed, additional plans will be necessary to provide co-
ordination between fire service and hospital serv-
ice. Such items as water supplies that can be used
for both fire control and decontamination should
be planned for. New hospital construction, or
renovation of present facilities, should follow the
codes that provide the best fire-resistive construc-
tion and the greatest protection against the spread
of fires within the structure. Locating hospitals
on large tracts of land that provide isolation from
combustible buildings is most practical because
in the event of a nuclear attack any lightly-con-
structed and combustible buildings nearby would
catch fire as a result of the blast, dislocating the
equipment within these buildings and augmenting
the thermal effect of the bomb itself, even though
they were many miles away from “ground zero.”

For several hours, fire departments would not
be able to cope with the numerous individual fires
because they would have to concentrate their
efforts where the fire fighting would be the most
effective and seemed most vitally needed to save
lives and critical property. Hospitals, of course,
would be high on the list, but since the available
manpower and equipment to aid hospitals would
be limited, the hospitals’ emergency plan for de-
fense against nuclear attacks will have to include
the best fire safety program that is practical and
that could be implemented by its own staff and
employees.

At the present time, it is impossible to determine
whether preparations for a nuclear attack will ever

412

Journal of Iowa Medical Society

July, 1962

be needed. Many people say a nuclear war can
never occur, and that the effort and cost to pre-
pare for one could be invested more wisely in
other fields of endeavor. Experience during the
past few years, however, has shown that war
tensions blow hot and cold, but in one way or an-
other world tensions never disappear. Our world
leaders are agreed that the present pattern is here
to stay for many years. The president of one of the
major public utilities said, several years ago when

his firm embarked on an all-out defense plan, “We
don’t know whether we are doing right or wrong,
but we do know we cannot afford to take a chance
on not being prepared.’’ Hospital and fire authori-
ties can be guided by this philosophy, since pre-
paredness for the worst that might happen could
easily be the difference between survival and ex-
termination in any given area of the country, in
case a nuclear-device attack were launched against
us.

State University of Iowa
College of Medicine

Clinical Pathologic Conference

SUMMARy OF CLINICAL FINDINGS

A retired male entered University Hospitals for
the second time at the age of 63 years. He had
been hospitalized here previously, at 51 years of
age, complaining of a severe precordial pain, with
radiation down the left arm, exertional dyspnea,
and occasional nocturnal crushing chest pain which
was relieved when he sat down. He had been dis-
charged on a low-salt diet, theophylline glycinate,
5 grains q.i.d., and phenobarbital. His history also
revealed that he had had an appendectomy in
1918, and that both his parents had died of heart
disease. He worked in a billiard parlor.

On the occasion of his second admission here,
he weighed 149 lbs., but he had weighed 200 lbs.
when he was hospitalized 12 years previously, and
indeed had lost 26 lbs. during the six weeks im-
mediately preceding his second admission.

About 5 weeks before he returned here, he had
been hospitalized elsewhere with acute pulmonary
edema. At the time of his discharge from that hos-
pital, his medications were digoxin, 0.5 mg., q.i.d.;
Diuril, 500 mg., b.i.d.; and nitroglycerin as needed.

Shortly, he developed continuous abdominal
pain, colic, bloating and cramping. Eating caused
the pain to worsen promptly or within 30 minutes.
The pain was located around and below the um-
bilicus, but was often diffuse. The abdominal pain
precipitated chest pains, but nitroglycerine sub-
lingually failed to relieve the abdominal pain as
it did relieve the chest pain. A barium motor meal
before admission was judged to reveal inflam-
matory changes in the distal ileum, and a bland
diet and antispasmodics were prescribed, but
without relief. He had not vomited, his stools con-

tained no gross blood or any indications of blood
on chemical testing, and he had never been
jaundiced.

The examination revealed a pale, chronically ill
patient in distress because of abdominal pain. His
blood pressure was 100/80 mm. Hg, his pulse was
108/min., and his respirations were 20/min. The
fundi showed grade II arteriosclerotic changes.
There was no hepatojugular reflex. There was no
cardiac enlargement, no murmurs were heard, and
the rhythm was normal. On abdominal examina-
tion, the appendectomy scar was noted. To palpa-
tion, the liver was 4 cm. below the costal margin,
and with auscultation the bowel sounds were ac-
tive. Of the major peripheral vessels, the temporal
and femoral arteries were palpably pulsatile.

The blood count, urinalysis, routine blood elec-
trolytes, creatinine and blood urea nitrogen were
within normal range — and they remained so.

The patient was plagued and disabled by chest
pain and abdominal pain. He shortly developed a
severe episode of chest pain, and was placed on
anticoagulants. After 24 hours, a precordial fric-
tion rub was heard over the fourth intercostal
space. The serum glutamic oxaloacetic transam-
inase determinations began with 15 sigma units,
and over five weeks ranged to 54 sigma units.
Numerous electrocardiograms were taken.

Roentgenographic and fluoroscopic oral alimen-
tary tract examinations were done, and they
showed dilated loops of small bowel, but no in-
trinsic small- or large-bowel lesions. At times, the
supine and erect views showed fluid levels and
dilatation, but at other times they were normal.

After one month of obsei'vation, the patient was
transferred to the surgical service. There, atten-

Vol. LII, No. 7

Journal of Iowa Medical Society

413

tion was directed to his abdominal condition, al-
though his cardiac difficulty had not appreciably
improved, and in addition, his right leg had be-
come troublesome, being painful and cooler than
his left. A barium enema was repeatedly delayed
because of his chest pain, but the examination was
finally made, and it outlined a normal colon with
no reflux into the small bowel.

After seven days of observation, the patient
began to vomit brown material, and the abdomi-
nal sounds were high-pitched, with protracted
rumblings. The abdominal girth was somewhat
enlarged. The small bowel displayed peristalsis
actively through the abdominal mass. There
were no signs of peritoneal irritation. The supine
and upright films were interpreted as normal. An
operation was decided upon.

During intubation, the patient became pulseless,
and closed-chest cardiac massage was instituted
immediately. Oxygen was supplied through the
intubation tube. An electrocardiogram showed
ventricular fibrillation, and on four occasions the
external defibrillator converted the patient to a
more normal mechanism, but it could not be sus-
tained, even with an external pacemaker. The
man was pronounced dead after an hour of such
efforts.

SUMMARY OF CLINICAL DISCUSSION

Dr. Robert Hickey, Surgery: This afternoon we
are concerned with a 63-year-old man who was
admitted to University Hospitals for the second
time after having been here at the age of 51. There
are three things of particular interest in the proto-
col. He had a very severe chest pain, he had se-
vere abdominal pain, and then he had an episode
which we considered cardiac arrest in the oper-
ating room.

Dr. Theilen has consented to discuss this case
as an unknown, but before we hear him, Mr. John
Haydon, junior ward clerk, will present the views
of the students.

Mr. John R. Haydon, junior ward clerk: Herman
Hein, A1 Healy, Charles Hickman and I were con-
fronted with the history of a 63-year-old man who
first came to this hospital 12 years ago with a
symptom complex consistent with that of angina
pectoris. His history revealed that both his par-
ents had died of heart disease. In 1918, he had had
an appendectomy. Over the past 12 years he had
lost 51 lbs., and 26 lbs. of that weight had dis-
appeared within the six weeks immediately prior
to his arrival here. On admission, he weighed 149
lbs.

Five weeks before he came here, he had been
hospitalized elsewhere with what appeared to be
congestive heart failure. His medication at dis-
charge from that hospital had been digoxin, 0.5
mg., q.i.d.; Diuril, 500 mg., b.i.d.; and nitroglycerin
as needed.

We feel that his weight loss can be explained
by the medication given him for his congestive

heart failure. However, this does not rule out
other causes for severe weight loss, such as neo-
plasms or tuberculosis. Shortly after his release
from the local hospital, he had developed con-
tinual abdominal pain, colic, bloating and cramp-
ing. Eating caused the pain to worsen promptly
or within 30 minutes. The pain was located around
or below the umbilicus, but often was diffuse. The
abdominal pain precipitated chest pains, but nitro-
glycerin sublingually failed to help the abdominal
pain as it relieved the chest pain. A barium motor
meal before admission had been thought to reveal
inflammatory changes in the distal ileum, and a
bland diet and antispasmodics had been prescribed,
but without relief. The patient had not vomited,
his stools contained no blood grossly or on chem-
ical testing, and he had never been jaundiced.

These findings lead us to consider the following
as possible causes of this man’s abdominal diffi-
culty: small-bowel obstruction, abdominal angina,
hiatal hernia, chronic pancreatitis, carcinoma of
the pancreas, biliary colic, renal colic, regional
enteritis and tuberculosis of the intestines.

Physical examination on the patient’s last ad-
mission to University Hospitals revealed a chron-
ically ill man still suffering from abdominal pain.
The low blood pressure and the findings of arterio-
sclerotic changes on fundoscopic examination sup-
port the possibility that he had abdominal angina.
His having a normal-size heart is surprising in
view of his apparent history of congestive heart
failure. In this connection, we have considered the
possibility of tuberculous pericarditis and tuber-
culosis of the small bowel. The small heart, nar-
row pulse pressure, high venous pressure and
bowel symptoms would tend to support this diag-
nosis. A palpable liver, 4 cm. below the costal
margin, would be an expected finding in a patient
with congestive failure. The presence of active
bowel sounds tends to rule out small-bowel ob-
struction on the basis of chronic vascular strangu-
lation due to mesenteric artery thrombosis or vas-
cular strangulation on a neurogenic basis. The
laboratory tests were non-contributory.

The patient continued to have abdominal and
chest pains, and apparently suffered a myocardial
infarct shortly after admission, as evidenced by an
episode of severe pain and the development of a
precordial friction rub. The S.G.O.T., however,
was not significantly elevated. In this connection,
a pulmonary infarct has been considered, and it
might well be consistent with the above enumer-
ated signs and symptoms.

Later, periodic x-ray examinations of the ali-
mentary tract revealed evidence of a small-bowel
obstruction. Although no intrinsic small-bowel
lesions were noted, it is not uncommon for them
to be missed by competent radiologists.

One month after admission, the patient de-
veloped pain in the right leg, and the right leg
was cooler than the left. We explain those findings

414

Journal of Iowa Medical Society

July, 1962

on the basis of a vascular occlusion following em-
bolization of the mural thrombus of the heart.

Seven days later, the patient began to vomit
brown material. The abdominal sounds were high-
pitched, and there were protracted rumblings.
The small bowel could be seen to display peri-
stalsis actively, through the abdominal wall.
These findings seem to indicate complete low
small-bowel obstruction.

An operation was decided upon, and during
intubation the patient became pulseless. An elec-
trocardiogram showed ventricular fibrillation. It
was impossible to convert the patient to a sus-
tained sinus mechanism, and he was pronounced
dead after an hour of attempts to do so.

This man seems to have shown the signs and
symptoms compatible with two progressive dis-
eases. The first is generalized arteriosclerosis. Fea-
tures supporting such a diagnosis include a his-
tory of angina pectoris, retinal changes, peripheral
embolism and myocardial infarction. Abdominal
angina — another feature of this process — could well
explain the abdominal pain. Progressive ischemia
of the bowel wall occurs during periods of in-
creased oxygen demand, namely active digestion.
A low perfusion pressure was evidenced by a blood
pressure of 100/80 mm. Hg, and this may have been
a contributing factor. As Dr. W. B. Bean brought
out in one of his monographs, loss of weight may
be due to the patient’s refusal to eat because of
his constant association of pain with eating. The
use of nitroglycerin and other antispasmodics is
often ineffectual in relieving abdominal angina.
Larger doses are frequently required than for
angina pectoris.

The other process involved, we think, was in-
termittent small-bowel obstruction. The causes
would include neoplasm, hernia and adhesions.
The vascular etiology — i.e., thrombosis — generally
is intermittent in character, rather than abrupt
and devastating. However, the terminal and com-
plete obstruction might well be explained on this
basis.

We aren’t told that a hernia was found, but the
possibility of an intraabdominal hernia cannot be
ruled out. Adhesions could be a distinct possibil-
ity, for the patient had had an appendectomy, but
we should have expected a difficulty of that sort
to have become apparent sooner.

Small-bowel neoplasm is our last consideration.
X-ray examination revealed no intrinsic lesions,
but we understand that this lesion cannot be
ruled out on the basis of a negative x-ray. Yet,
neoplasms of the small bowel are extremely un-
common.

Our final anatomical diagnosis would consist of:
(1) generalized arteriosclerosis, with arterioscle-
rotic heart disease, congestive heart failure, myo-
cardial infarction, insufficiency of the coronary
arteries and peripheral embolization; and (2) low
small-bowel obstruction resulting at first from

mesenteric artery insufficiency with associated
abdominal angina, and finally from mesenteric
arterial embolic occlusion.

Dr. Hickey: Thank you, Mr. Haydon.

Now Dr. Theilen, we have a number of radio-
graphs which you may have with or without an
accompanying radiologist, or if you choose, we
can provide electrocardiograms with or without
interpretations.

Dr. E. O. Theilen, Internal Medicine: Your gen-
erosity in offering all of the data makes me a bit
wary, for it suggests that the problem may not be
so obvious as it seems to be on the basis of a pre-
liminary survey of the available information.

This patient showed some of the ravages of de-
generative vascular disease at a relatively early
age. I think most of you would agree that he prob-
ably had coronary atherosclerosis and angina pec-
toris when he was first seen here at the age of 51.
There isn’t much point in my commenting now
upon the therapy that was given him at that time.

Six weeks before his second and last admission
here, he is said to have had acute pulmonary
edema, presumably due to left ventricular fail-
ure. No comments were made about signs of right
heart failure, although I presume that these might
very well have been present since it is unlikely
that selective failure of one ventricle could per-
sist for an appreciable length of time.

The problem of the patient’s weight loss should
also be considered in relation to his possible con-
gestive heart failure. A 26-pound weight loss in
six weeks seems excessive unless it can be ex-
plained in part by fluid loss. Anorexia because of
chronic passive congestion of the viscera could
account for part of his weight loss, but it is also
possible that treatment with diuretics might have
brought about a large part of the weight change.
A gastrointestinal lesion must be considered, as
well, in a patient with weight loss and a history
of abdominal pain.

The abdominal pain from which this man suf-
fered presents several interesting possibilities from
the standpoint of diagnosis. It apparently began
before he came to this hospital and while he was
still being treated for his heart disease. Could this
have been from congestive heart failure? It seems
somewhat unlikely. Abdominal pain from stretch-
ing of the liver capsule as the result of chronic
passive congestion is well recognized, but I would
not expect it to be cramping. The pain is described
as periumbilical, and one thing which is perhaps
quite significant is that it increased consistently
after meals. The usual interval was said to be
about 30 minutes. Several things come to mind
when I examine this particular facet of his history.
Pancreatitis must be considered. It certainly could
account for rather severe abdominal pain that
might be accentuated by eating. Pancreatitis might
also account for some of the dilated loops of small
bowel seen from time to time in some of the

Vol. LII, No. 7

Journal of Iowa Medical Society

415

gastrointestinal studies. I don’t think that we can
exclude involvement of the pancreas at this time.

I should like to know whether or not, during
the course of this man’s illness, any measurements
were made of serum amylase or lipase, or whether
any enzyme studies were done on fluid obtained
from the peritoneal cavity.

Dr. Hickey: He had one amylase determination.
It was 64 units on admission.

Dr. Theilen: Unfortunately, that doesn’t help us
a great deal. A high value would have been sig-
nificant, but I don’t think that one amylase de-
termination of 64 units necessarily excludes a
pancreatitis. Another thing that makes a diag-
nosis of pancreatitis somewhat untenable is the
lack of any obvious etiologic factors. There is no
history of biliary-tract disease, and as far as we
know this patient was not an alcoholic. There is
no history of trauma to the abdomen which might
have precipitated a pancreatitis. Pancreatitis sec-
ondary to vascular insufficiency is also unlikely.
Infarction of the pancreas, as far as I know, is a
very rare cause of pancreatitis.

Now let’s turn to some other possibilities such
as obstructing lesions of the bowel. Could this
man have had a volvulus of the small bowel or
an obstruction on the basis of intraabdominal ad-
hesions, or did he have an intrinsic lesion of the
bowel? I am inclined to rule out the possibility
of a small-bowel carcinoma because I think that
someone would have been able to demonstrate a
defect on at least one of the gastrointestinal x-ray
examinations and motor meals. What about re-
gional enteritis as a cause of small-bowel obstruc-
tion? This was suggested by the first motor meal
that was done before admission to the University
Hospitals. Some inflammatory changes were said
to be indicated. Dr. Keller, are those particular
films available for examination?

Dr. John T. Keller, Radiology: No, we have
only our own films.

Dr. Theilen: I gather that no signs of regional
enteritis were demonstrated on several examina-
tions here. Barium will often reflux into the ter-
minal ileum during a colon series in a patient
with regional enteritis. This did not occur in this
man. The so-called “string” sign was not found. If
this man had had regional enteritis of sufficient
severity to produce symptoms of intestinal obstruc-
tion, I should think one would have been able to
visualize some abnormality in the small bowel, but
apparently none was found.

Could this man have had a volvulus? It should
have been possible to rule out volvulus of the
sigmoid rather easily, since the physical and radio-
graphic findings are rather characteristic. The
clinical picture doesn’t suggest volvulus of the
sigmoid. We cannot be quite so certain, however,
about intermittent volvulus of the small intestine.
The close relationship of this man’s pain to eating
weighs against this possibility, however.

Finally, I should like us to consider an impair-
ment of the arterial blood supply to the gastroin-
testinal tract as the cause of this man’s difficulties.
It perhaps is significant that he had pain which
was precipitated by eating, or occasionally pain
that was accentuated by eating. Perhaps his weight
loss was due in part to his desire to avoid pain
by not eating. On the other hand, some of his
weight loss might have occurred as the result of
malabsorption secondary to vascular insufficiency,
even though he didn’t have diarrhea, which we
would ordinarily associate with malabsorption
syndromes. Dilated loops of small bowel were seen
on some of the x-rays. I wonder whether we may
examine some of the films at this time, Dr. Keller.
It is even possible that some of the inflammatory
changes described by the physicians who referred
the patient could have been secondary to an in-
sufficiency of blood flow through the superior
mesenteric artery. Vascular insufficiency in the
intestinal tract can sometimes mimic regional
enteritis, and may produce some changes in the
mucous membrane.

Dr. Keller: This is a film taken 24 hours after
the motor meal, and it shows several dilated loops
of small bowel containing considerable amounts
of barium. Another film taken after the admin-
istration of a barium enema shows multiple loops
of small bowel dilated by gas, but shows no reflux
of barium through the ileocecal valve.

Dr. Theilen: Would you regard these changes
as non-specific?

Dr. Keller: Yes. We don’t see any specific lesion,
but would perhaps say that the changes are indic-
ative of partial small-bowel obstruction.

Dr. Theilen: Thank you. We must not forget
that this man's cardiovascular function was com-
promised in other respects. He had coronary ath-
erosclerosis. He probably had a rather low cardiac
output, or at least could not maintain a very satis-
factory blood pressure. He had a blood pressure
of only 100/80 mm. Hg. It is quite possible that
he might have had an atheromatous plaque in-
volving the superior mesenteric artery. A decrease
in cardiac output following either a myocardial
infarction or after congestive heart failure could
very easily accentuate the manifestations of su-
perior mesenteric artery insufficiency in such a
circumstance. In fact, I should expect this to be
the situation. I wonder whether anyone listened
for bruits over the abdominal aorta.

Dr. Hickey: No bruits were detected.

Dr. Theilen: Thank you. Unfortunately, the ab-
sence of such findings does not rule out abdominal
angina, although I certainly would be much more
confident of such a diagnosis if a bruit had been
heard.

This man next had a catastrophic episode, as
far as his chest was concerned. He had severe
chest pains, and developed a precordial friction
rub which I presume was synchronous with the

416

Journal of Iowa Medical Society

July, 1962

heart beat rather than with respiration. Is that
correct?

Dr. Hickey: Yes.

Dr. Theilen: I should expect that he had a myo-
cardial infarction despite the transaminase values.
Dr. Hickey, may I see one of his electrocardio-
grams that were taken at that time?

Dr. Hickey: These are a group of tracings be-
ginning on the day of his admission.

Dr. Robert J. Joynt, Neurology: Are there pro-
gressive changes?

Dr. Theilen: The tracings do show progressive
changes. The diagnosis of acute myocardial in-
farction seems well established. Following this
episode, he developed further signs of vascular
insufficiency, but this time in another area with
symptoms referable to the right leg. He began to
deteriorate, and I am sure that the active peristal-
sis and other signs that he developed were in-
terpreted as indicating intestinal obstruction. I
understand that there were no radiographic signs
of obstruction at that time. Is that correct, Dr.
Keller?

Dr. Keller: That is correct.

Dr. Theilen: Although the physical findings
would suggest acute obstruction, this certainly
does not have to be on a mechanical basis such as
a volvulus or a stenosing lesion. It could easily be
due to an acute occlusion of the superior mesen-
teric artery. Loss of function in an ischemic seg-
ment of bowel will act like a mechanical obstruc-
tion.

Taking everything into consideration, I am sure
that this man’s physicians had no choice but to
explore him in the hope that he might have a
remediable lesion. Unfortunately, he died as a
result of ventricular fibrillation. He presented a
definite risk, as far as his heart was concerned,
but I don’t believe that there was an alternative
to operating on him. I don’t think we can point a
finger of suspicion at any one thing other than his
heart disease as the precipitating factor in the
cardiac arrest and ventricular fibrillation, and I
really am not surprised that it occurred.

Why should there have been difficulty in re-
suscitating the patient? Good coronary perfusion
must be present if one is to succeed in resuscitat-
ing a fibrillating heart. Unless the myocardium is
well oxygenated, attempts at reestablishing a nor-
mal rhythm are seldom successful. Coronary
atherosclerosis might have prevented adequate
coronary perfusion, even though cardiac massage
were done properly.

I predict that this man will be found to have
had severe coronary atherosclerosis and a recent
myocardial infarction. Peripheral atherosclerosis,
with involvement of the superior mesenteric
artery, will probably be found, and I anticipate
that the pathologists will have found a segment of
necrotic bowel on the basis of superior mesenteric
artery occlusion.

Dr. Hickey: Thank you very much, Dr. Theilen.
Are there any questions, alternate interpretations
or other explanations for this man’s hospital
course?

Dr. James Clifton, Internal Medicine: I should
like to ask about this man’s bowel movements. Did
he have diarrhea or constipation?

Dr. Hickey: At times he was constipated and
had an increase in abdominal girth. Then at other
times he was completely normal. He had no
marked diarrhea, but also had no marked consti-
pation.

Dr. George N. Bedell, Internal Medicine: Dr.
Hickey, what was the clinical diagnosis at the time
the patient was taken up for exploration?

Dr. Hickey: The clinical diagnosis was intestinal
obstruction.

Dr. Bedell: You didn’t want to commit yourself
as to the basis of the obstruction?

Dr. Hickey: We had the background, and per-
haps we gave special weight to the inflammatory
changes of regional enteritis that were described
in the interpretations of radiographs made else-
where. Secondly, this man had had an abdominal
operation, an appendectomy, and even though it
had been some time since that procedure was
done, we felt that this man had a low intestinal
obstruction. We operated upon him with the diag-
nosis of intestinal obstruction on the basis of
either regional enterititis or adhesions. On the
other hand, he also had the secondary diagnosis
of abdominal angina.

Dr. F. W. Stamler, Pathology : The significant
autopsy findings were those concerning the heart
and the small intestine. The heart was consider-
ably enlarged, and the increased size mostly in-
volved the left ventricle. With the enlargement,

Figure I. Stenosing lesion in a loop of small bowel found
in the pelvis. The constricted portion is clearly shown, with
greatly dilated ileum proximal, and normal ileum distal to
the diseased portion. Note that there is little evidence of
serosal inflammation or of the mesenteric scarring that is
often seen with regional enteritis.

Vol. LII, No. 7

Journal of Iowa Medical Society

417

there was very extensive myocardial fibrosis in-
volving almost the entire left ventricle. In this
fibrotic myocardium, no gross fresh infarct was
described, but microscopically there was quite ex-
tensive recent myocardial infarction. The patient
probably had had a series of myocardial infarcts
or continuing ischemic damage to the myocardium
extending over a considerable length of time.
There was a rather generalized and severe coro-
nary atherosclerosis, but no fresh occlusion was
detected in any of the coronary vessels. The fact
that cardiac massage was unsuccessful in reinsti-
tuting the cardiac action was readily explained
on the basis of this extensive damage. We have
good evidence that this massage was carried on
with considerable vigor, in that there were a

Figure 2. The opened ileum demonstrates the great de-
gree of stenosis and thickening of the diseased portion, and
the rather sharp transition between involved and normal por-
tions.

number of ribs fractured — the third, fourth and
fifth ribs on the left, and the third, fourth, fifth
and sixth ribs on the right. A rather sizable hema-
toma was associated with this.

The ileum displayed a 15 cm. area of stenosing
fibrosis and chronic ulceration 120 cm. above the
ileocecal valve. It caused almost complete obstruc-
tion to the bowel at that point. There were old
fibrous omental adhesions to the anterior peri-
toneum in several areas, indicative of some past
inflammatory episode, but there was no peritonitis
at the time of autopsy. The stenosing lesion of the
ileum was interpreted as a type of regional ileitis.
It was somewhat more proximal in location than
is usual in this disease, and also somewhat atypical
as regards the nature of the inflammatory response.
The chronic fibrosing lesion showed very little of
the granulomatous inflammation that is present
in many lesions of regional ileitis.

The first photograph I wish to show is of the
stenotic lesion of the small bowel (Figure 1). This
loop of bowel was found within the pelvis, but was
freely delivered from that location. The constricted
portion is clearly shown, with greatly dilated ileum
proximal, and normal ileum distal to the diseased
portion. You will note little evidence of serosal
inflammation or the mesenteric scarring which is
often seen with regional enteritis. The next photo-
graph (Figure 2) shows the opened ileum, dem-
onstrating the great degree of stenosis and thick-
ening of the diseased portion, and the rather
sharp transition between involved and normal
portions.

The entire thickness of the diseased bowel wall
is shown in the next photograph (Figure 3). The
mucosa is entirely denuded of epithelium, and
normal stroma has been replaced by chronic gran-
ulation tissue. The muscularis mucosa is repre-
sented by remnants of smooth muscle, beneath
which a greatly thickened, fibrotic and chronical-
ly inflamed submucosa extends to relatively nor-
mal muscularis. The subserosa also shows mild
fibrosis and chronic inflammation. There is little
evidence of the chronic granulomatous inflam-
mation sometimes seen in regional enteritis, al-
though an occasional multinucleated giant cell is
seen in the submucosa, and clusters of mono-
nuclear cells in dilated lvmphafics illustrate an-
other feature of regional enteritis that is often
stressed.

The next photograph illustrates the degree of
scarring present in the left ventricle (Figure 4),
whereas other areas showed myocardial necrosis
and focal neutrophilic infiltration characteristic
of an infarct of a few days’ duration. The exten-
sive myocardial disease resulting in irreversible
cardiac standstill was the immediate cause of
death.

These were the essential findings. The vascular
system elsewhere showed no unusual degree of
arteriosclerosis. The mesenteric vessels and aorta

418

Journal of Iowa Medical Society

July, 1962

were moderately well preserved. There was no
evidence of ischemic changes of the bowel in re-
lation to vascular occlusion.

Dr. Hickey: Was the superior mesenteric artery
patent?

Dr. Stamler: The autopsy protocol states that
the superior mesenteric artery was entirely free
of disease.

Dr. Raymond F. Sheets, Internal Medicine: Were
there any blood clots in the right leg?

Dr. Stamler: I believe not.

Dr. Hickey: Dr. Lawrence, would you discuss
the resuscitative procedures? What do you think
of the technic that was used? Are you surprised
at the number of fractured ribs? How, ideally,
would you go about resuscitating a patient under
normal circumstances?

Dr. Montagu Lawrence, Surgery: If a patient
has a cardiac arrest and there is justification for
reviving him, survival depends upon the simula-
tion of the action of the heart to perfuse the brain
and the coronary arteries. Prior to January, 1960,
the method of choice was open thoracotomy with
cardiac massage. Since that time, however, closed-
chest massage has been very popular and reward-
ing. There are advantages and disadvantages of
both methods. Actually, I think I like the closed-
chest technic better, but I have jotted down some
advantages of each.

Here, then, are the advantages of open massage.
1. The operator is able to determine the status of
the heart and the coronary vessels, and to decide
what drugs should be given. For example, if the
heart is dilated, he might like to give the patient
calcium. If the heart is fibrillating, he might give
epinephrine to increase the coarseness of the
fibrillations so that defibrillation would be much
easier. 2. One can observe directly the response
of the heart to the drugs, and can direct defibril-
lation with greater certaintly. 3. If drugs are ad-
ministered, they may be injected directly into the
left ventricle without injury to the coronary ves-
sels, or if one wants to cross-clamp the aorta dis-
tal to the coronary artery, he can easily inject
drugs at a point proximal to that clamp so as to
perfuse the coronary arteries directly. Or if he
wishes to cross-clamp the aorta distal to the left
subclavian artery, so that all available blood will
go directly to the brain and the coronaries, he
can easily do that after opening the chest.

Now, the advantages of closed-chest massage.
1. It can be started immediately. 2. On the avei’age,
I think, better cardiac output is obtained with
closed cardiac massage — i.e., massage of the
heart between the posterior sternum and the
vertebral bodies. 3. With closed cardiac massage,
one avoids the complications of the “slashers.”
There is no rupture of the heart, and there is no
laceration of the lung or coronary arteries such
as we see quite frequently following open cardiac
massage. 4. Closed cardiac massage may be in-

Figure 3. This shows the entire thickness of the diseased
bowel wall. The mucosa is entirely denuded of epithelium,
and normal stroma has been replaced by chronic granula-
tion tissue.

definite as long as there is evidence of a peripheral
pulse and as long as there is a satisfactory blood
pressure.

Trained personnel must be available for direct
massage. If there is a delay in opening the thorax,
the chance of survival is lessened. Because of the
excitement and the “wild man” desire to get into
the chest to massage the heart, the operator quite
frequently produces lacerations through the fe-
male breast, lacerations of the emphysematous
lung that is usually present in the older patient,
laceration of the heart, laceration of the coronary
arteries, perforation of the right atrium and
ventricle by his massaging fingers, or hematomas
within the myocardium. If one chooses the closed-
chest technic, he can start the massage immedi-
ately. However, extra gadgets will be needed. If
one starts closed cardiac massage and there is no
spontaneous return of pulse or blood pressure, the
patient should be monitored with an electrocardio-
graph and, if there is extensive evidence of fibril-
lation of the heart, external defibrillation will be
needed. A sufficient force to provide an adequate
peripheral pulse and blood pressure may produce
fractures of the sternum, sternoclavicular separa-

Vol. LII, No. 7

Journal of Iowa Medical Society

419

Figure 4. This illustrates the degree of scarring present
in the left ventricle.

tion, fractures of the ribs, hemorrhagic lung and,
very rarely, rupture of the liver, spleen or
stomach. I think I could defend anyone who frac-
tured the anterior thoracic cage while giving
cardiac massage, on the grounds that such com-
plications are easily corrected. Most of the com-
plications from open cardiac massage, on the other
hand, are not easily remediable.

In children, the chest is very pliable, and com-
plications such as fractures of the chest wall sel-
dom develop. However, in older people, the ones
who frequently have cardiac arrest, the ribs are
quite friable, and it has been said that some ribs
may have to be cracked in order to produce ade-
quate blood pressure by means of massage. I
don't recommend the deliberate fracture of ribs
for this purpose, however, and I suspect that the
statement I have just quoted was made by an
operator who had been too vigorous in his mas-
saging efforts, and wanted an excuse for the dam-
age he had done.

Finally, I should like to outline methods which
I believe are satisfactory for cardiac resuscitation.
Initially, closed-chest massage should be under-
taken. An electrocardiogram should be made,
especially if spontaneous action does not take
place. Then external shockers should be used, and

if action still does not recommence, one may con-
tinue the massage. If repeated shocking does not
revive the patient, then one should undertake
open pericardotomy, inspection of the heart, drug
administration, direct massage, and defibrillation
of the heart, if possible.

Dr. Hickey: If I may, Dr. Bedell, I’d like to re-
turn to your question about the clinical diagnosis
that was made by the attending surgeons. This
man was so ill when he was transferred from the
medical to the surgical service, that we were un-
able to obtain an adequate x-ray of his alimentary
tract. Repeatedly, he was scheduled for x-ray
examination, but the radiologist said the risk was
too great and the procedure was postponed for
another day.

We suspected very strongly that this man had
an intermittent mesenteric ischemia. Perhaps Dr.
Bean should be the one to discuss this entity, for
as you students are possibly aware, he published
an article on it in the January, 1957, issue of
annals of internal medicine.* In the case that he
reported in that paper, the patient was a 41-year-
old man who had had severe attacks of abdominal
pain that were quite similar to those that this
more recent patient experienced. Initially the
pains were colicky, and then they became more
constant. Pains were associated v/ith food, and
early in his course he had pain when he ate fatty
foods. Later, pain followed the ingestion of any
type of food, and then he lost a considerable
amount of weight.

This previous patient apparently got some relief
from pain by sitting in a bent-forward position.
The x-rays on him were equivocal, but there were
some suggestive changes in the third portion of
the duodenum, and he was operated upon with a
tentative diagnosis of carcinoma of the pancreas.
He died 66 hours postoperatively. At the time of
the operation, no abnormality was detected in the
mesenteric vessels, but they were not examined
in detail, I must admit, for at postmortem he was
found to have had a complete occlusion of the
superior mesenteric artery — i.e., a partial occlusion
had become complete. The superior mesenteric
artery is very important. The arterial perfusion
extends through the entire small bowel, part of
the duodenum and to the left side of the colon.
I am sure that the symptoms and the ability of
the patient to withstand this type of partial oc-
clusion would depend upon the degree of anasto-
mosis that could take place.

As time progressed, the patient whom we have
been discussing today seemed quite obviously to
have an intestinal obstruction, and as I have re-
lated, we thought the cause must be a band from
his appendectomy, performed long in the past. Of
course, we were aware of the other possibilities,

* Sedlacek, R. A., and Bean, W. B.: Abdominal “angina”:
syndrome of intermittent ischema of mesenteric arteries.
ann. int. med., 46:148-152, (Jan.) 1957.

420

Journal of Iowa Medical Society

July, 1962

but we didn’t place great weight upon them for
the reasons that Dr. Theilen has listed. The patient
was of the wrong age to have regional enteritis.
He had an intestinal obstruction, and he needed
therapy as a surgical emergency. We felt that his
condition could proceed from the chronic stage to
an acute situation, with strangulation which would
bring about necrosis of the bowel, perforation,
peritonitis and, probably, death.

With respect to the entities that would produce
intestinal obstruction in a patient of this man’s
age, we should, of course, consider carcinoma as
number one. Second, we should consider old ad-
hesions, and finally, hernia. This man did not have
a hernia. The various other entities would be
volvulus and inflammatory changes, and the things
that could confuse us would be the mesenteric
difficulties due to arterial insufficiency, pancrea-
titis and metabolic diseases.

Dr. Edward E. Mason, Surgery: For many years,
congenital atresia of the bowel was thought to be
a failure of recannulization during development,
and then it was discovered during animal experi-
mentation that if one ligates vessels to the mesen-
tery of the small bowel of the fetus in utero and
then lets the bitch go to term, the pups have
typical congenital strictures and yet the lesion in
the blood supply cannot be identified. This man
had a myocardial infarction and could have had
endocardial thrombi, one of which could have
lodged in a vessel in a segment of bowel. Result-
ant damage could have led to this strietured area.
Is there anything in the pathologic findings that
would be inconsistent with this idea?

Dr. Stamler: No lesion of the mesenteric vessel
was detected at autopsy. I am not sure that the
examination was thorough enough for us to be
entirely certain that a vascular lesion wasn’t over-
looked. I should say, however, that an embolic
phenomenon or any vascular disease severe
enough to cause a high degree of ischemia to a 15
cm. segment of bowel probably would be severe
enough to cause infarction at the time it occurred,
with resulting gangrene and intestinal rupture and
peritonitis, rather than the chronic stenosing
lesion that we now see. I’m only stating an opin-
ion, however, and I’m willing to entertain con-
trary views.

Dr. Mason: In a patient who was studied here
on the metabolism ward for a few years, we final-
ly made the diagnosis of abdominal angina and
found that there were segments of bowel that
quite obviously were ischemic. There were ad-
hesions around that bowel, and a lot of fibrosis.
I think it was almost the same picture that you
see here. That patient did, however, have narrow-
ing of the mesenteric artery.

Dr. Hickey: This man had no evidence of nar-
rowing. As a matter of fact, there wasn’t even a
plaque.

Dr. Mason: What I postulate is an embolus — not
arteriosclerotic narrowing but a remote occlusion
which caused ischemic damage. Then, with time,
the occluded vessel may have recannulized or
otherwise may have become less obvious, leaving
the patient with a stenosing, scarred segment of
bowel.

Dr. W. B. Bean, Internal Medicine: Was this
case similar to the one we discussed two weeks
ago? In that patient, a woman, there was a tumor
embolus that might have been causing upper-ab-
dominal pains which seemed very mysterious to
me. I thought that if this obstruction were severe
enough to cause an infarct, it would produce
gangrene, with infarction of the gut. There was
an infarct from a tumor embolus of the mesenteric
artery, was there not?

Dr. George Zimmerman, Pathology: We attrib-
uted the chronic difficulties that she had to the
tumor embolus. We postulated that there had been
a recent thrombosis superimposed upon the long-
standing embolus and resulting infarction of the
bowel.

STUDENTS' DIAGNOSES

1. Generalized arteriosclerosis, with arterioscle-
rotic heart disease, congestive heart failure, myo-
cardial infarction, insufficiency of the coronary
arteries and peripheral embolization

2. Low small-bowel obstruction resulting from
mesenteric artery insufficiency with associated
abdominal angina and, finally, mesenteric arterial
embolic occlusion.

DR. THEILEN'S DIAGNOSES

1. Coronary atherosclerosis, with recent myo-
cardial infarction

2. Peripheral atherosclerosis, with involvement
of the superior mesenteric artery

3. Necrotic bowel secondary to vascular oc-
clusion.

CLINICAL DIAGNOSIS

Intestinal obstruction.

ANATOMIC DIAGNOSES

1. Chronic regional ileitis

2. Arteriosclerotic heart disease, with (a) coro-
nary arteriosclerosis, (b) cardiac hypertrophy and
myocardial fibrosis, and (c) myocardial infarct,
recent

3. Arteriosclerosis, generalized, moderately ad-
vanced

4. Omental adhesions, old

5. Hyperplasia, prostate

6. Fractures, 3rd, 4th and 5th ribs, left; and 3rd,
4th, 5th and 6th ribs, right

7. Aspiration of blood, tracheobronchial system.

Coming Meetings

CONTINENTAL U. S. ABROAD

July 1-4

July 3-8

July 5-6

July 9-12

July 9-13

July 13-14
July 16-27
July 19-21
July 23-27

July 23-
Aug. 3

July 30-
Aug. 3

Aug. 2-4

Aug. 6-10

International College of Surgeons’ New Eng-
land Regional Meeting. Mt. Washington Hotel,
Bretton Woods, N. H.

Seminar for General Practitioners (UCLA).
University Residential Conference Center,
Lake Arrowhead, California
Practical Applications in the Management and
Rehabilitation of Arthritis. University of Col-
orado Medical Center, Denver
Medical and Surgical Aspects of the Retina
(University of Colorado School of Medicine)
and Summer Convention of the Colorado
Ophthalmological Society. The Stanley Hotel,
Estes Park, Colorado

Obstetrics, General and Surgical. Cook Coun-
ty Graduate School of Medicine, Chicago

Dermatology for General Practitioners. Uni-
versity of Colorado Medical Center, Denver

Cardiopulmonary Problems in Children (Amer-
ican College of Chest Physicians). Edgewater
Beach Hotel, Chicago

Surgical Technic. Cook County Graduate
School of Medicine, Chicago
Audiology Workshop (University of Colorado
Medical Center). Estes Park, Colorado

Anesthesiology. University of California, Los
Angeles

International Society for Clinical and Experi-
mental Hypnosis. Benson Hotel, Portland,
Oregon

Fifth Annual Postgraduate Course in Pedi-
atrics (University of Colorado Department of
Pediatrics and the Office of Postgraduate
Medical Education). Stanley Hotel, Estes Park,
Colorado

Aug. 12-15

Aug. 15-19

Aug. 16-18
Aug. 19-25

Seminars in Internal Medicine (UCLA). Uni-
versity Residential Conference Center, Lake
Arrowhead, California

Pediatrics (UCLA). University Residential
Conference Center, Lake Arrowhead, Cali-
fornia

Evaluation of Therapeutic Agents and Cos-
metics. University of California at Los Angeles

International Congress for Microbiology. Mon-
treal, Canada

Aug. 24-25 Endocrine Aspects of Obstetrics and Gyne-
cology. University of California, Los Angeles

Aug. 25 American Institute of Ultrasonics in Medicine.

Biltmore Hotel, New York City

Aug. 26-27 American Academy of Physical Medicine and
Rehabilitation. Hotel Commodore, New York
City

Aug. 26-Sept. 1 The Special Child in Century 21 (Second Na-
tional Northwest Summer Conference). Health
Sciences Auditorium, University of Washing-
ton, Seattle

Aug. 26-Sept. 1 International Congress of Radiology. Queen
Elizabeth Hotel, Montreal, Canada
Aug. 27-30 American Association of Clinical Chemists.

Mira Mar Hotel, Santa Monica, California
Aug. 28-31 American Congress of Physical Medicine and
Rehabilitation. Hotel Commodore, New York
City

Aug. 28-Sept. 5 Fifth World Congress on Electron Microscopy.
Philadelphia

Aug. 29-30 Medical Aspects of Athletics. University of
California San Francisco Medical Center,
Berkley Campus

Aug. 30-Sept. 8 American Society of Clinical Pathologists.
Palmer House, Chicago

July 1-4

July 1-7

July 8-12

July 28-
Aug. 3

July 30-
Aug. 13

Aug. 8-15

Sept. 3-7

Sept. 5-8

Sept.

Sept. 5-8
Sept. 9-15

Sept. 9-15

Sept. 11-17
Oct.

Oct. 2-5
Oct. 7-13
Oct. 22-28

Nov. 11-16
Dec.

Feb. 20-24,
1963

International Conference on Oral Surgery.
Royal College, London. Write: D. C. Trexler,
Executive Secretary, American Society of Oral
Surgeons, 840 North Lake Shore Drive, Chica-
go 11

From Disability to Work (The British Coun-
cil for Rehabilitation of the Disabled), Euro-
pean International Study Course and Confer-
ence. Cambridge University, London
International Congress of Psychosomatic Med-
icine and Childbirth. Paris. Contact: Dr. L.
Chertok, 22 rue Legendre, Paris 17, France
Pan American and South American Pediatric
Congress. Quito, Ecuador. Write: Dr. Jorge
Vallarino, P.O. Box 2269, Quito, Ecuador
Fifth Annual Refresher Course (University
of Southern California). Royal Hawaiian
Hotel, Honolulu, and on S. S. Matsonia. Ad-
dress: Phil R. Manning, M.D., Associate Dean
Postgraduate Division, U.S.C. School of Med-
icine, 2025 Zonal Avenue, Los Angeles 33
International Fertility Association, 4th World
Congress, Hotel Copocabana, Rio de Janeiro.
Write: Dr. Maxwell Roland, Secretary, 109-23
71st Road, Forest Hills 75, New York
First International Conference on Water Pol-
lution Research. London. Write: Mr. W. Wes-
ley Eckenfelder, Jr., Manhattan College En-
vironmental Engineering Research Laboratory,
514 Sylvan Avenue, Englewood Cliffs, New
Jersey

Sixth International Society of Audiology Con-
gress. Leiden, The Netherlands. Write: Dr.
Trenque, 4 rue Montvert, Lyon. France
Tenth International Congress of Pediatrics.
Lisbon, Portugal. Write: Prof. M. Cordeiro,
Clinica Pediatrica Universitaria, Hospital de
Santa Maria, Av. 28 de Maio, Lisbon, Portugal
Ninth Congress of the International Society of
Haematology. Mexico, D. F. Write: Prof. G.
Mathe, 11 bis rue Vanentin-Haiiy, Paris,
France, or Dr. J. L. Tullis, 1190 Beacon Street,
Brookline 46, Mass.

Twenty-second International Congress of
Physiological Sciences. Leiden, The Nether-
lands. Write: Dr. J. van Noordwijk, Plderweg
20, Amsterdam-0, Netherlands
American Society of Plastic and Reconstruc-
tive Surgery, Hawaiian Village Hotel, Hono-
lulu. Write: T. Ray Broadhent, M.D., Sec-
retary, 508 East South Temple, Salt Lake City
International Congress for Prophylactic Medi-
cine and Social Hygiene. Bad Godesberg, West
Germany. Write: D. A. Rottmann, Liechen-
steinstrasse 32, Vienna, Austria
World Congress of Cardiology, Medical Cen-
ter, Mexico City. Write: Dr, I. Costero, In-
stituto N. De Cardiologia, Avenida Cuauhte-
moc 300, Mexico 7, D. F.

International Medical World Conference on
Organizing Family Doctor Care. Victoria Halls,
Southampton Row, London. Write: The Editor,
The Medical World, 56 Russell Street, Lon-
don, W.C.I.

421

422

Journal of Iowa Medical Society

July, 1962

Male Mental Acuity
Linked to Cholesterol

Research findings indicate that the level of cho-
lesterol in the blood has a “significant relationship
to mental acuity in men beyond the age of 40 to
45.” The findings were reported by Ralph M.
Reitan, Ph.D., and Robert E. Shipley, M.D., In-
dianapolis, in an exhibit at the AMA Annual
Meeting in Chicago.

Mental acuity was measured with a battery of
11 psychological tests covering a wide range of
abilities, such as reasoning ability, problem-solv-
ing, reaction time, and time sense, they said.

Subjects whose cholesterol levels were lowered
by 10 per cent or more over a 12 month period
were compared with subjects whose cholesterol
levels were not lowered, they said.

“Below the age of 45 years the groups per-
formed equally well on the psychological tests,”
the researchers said. “In persons beyond 45 years
of age, however, a clear difference was present.
The group in whom cholesterol levels were not
lowered performed significantly more poorly than
did the other group upon re-testing at the end of
the year.”

They concluded: “The results suggest that low-
ering of serum cholesterol level takes on special
significance after the age of 40-45 years, and leads
to improved retention of alertness and mental
acuity.”

Several research findings in recent years sug-
gest that mental acuity may be related to blood
cholesterol levels, according to Reitan and Ship-
ley.

Previous research by Reitan and Dr. Ward C.
Halstead at the University of Chicago Clinics dem-
onstrated a trend toward decreasing mental acuity
beginning at an average age of 45 years and pro-
gressing with age, although not true in all persons.

Investigation of the blood vessels of the brain
and other organs indicates that hardening of the
arteries become more manifest in the later dec-
ades of life, and that this may be related to the
cholesterol content of the blood, the two exhibit-
ors said.

These prior findings suggested the possible val-
ue in repeated measurements of mental acuity in
persons whose blood cholesterol levels had been
decreased through treatment compared with un-
treated subjects, they said.

Letter to the Editor

Sir:

I want to congratulate those who planned the
last scientific program of the Society’s meeting.

It was enjoyable and interesting. I find that
there are many doctors who agree with me in this
regard.

It will help to increase the attendance at the
meeting next year.

Sincerely yours,

Arthur E. Perley, M.D.

330 South Street
Waterloo, Iowa

IMS Past-Presidents

This cheery group of IMS past-presidents attended the 1962 Annual Meeting banquet. They are, left to right, top row: W. L.
Downing, M.D., LeMars; James E. Reeder, M.D., Sioux City; G. F. Harkness, M.D., Davenport; R. N. Larimer, M.D., Sioux City;
O. N. Glesne, M.D., Fort Dodge; Ben T. Whitaker, M.D., Boone; and J. W. Billingsley, M.D., Newton. Bottom row: Robert L.
Parker, M.D., Des Moines; W. D. Abbott, M.D., Des Moines; Thomas F. Thornton, M.D., Waterloo; H. A. Spilman, M.D., Ot-
tumwa; and Fred Sternagel, M.D., West Des Moines.

Our Elderly Aren't All III

With all the fanfare over the King-Anderson
Bill there are several aspects of the care of the
aged which have not been given sufficient consid-
eration.

One erroneous concept is the equating of old
age with long-term illness. It is the general im-
pression that we have from 17 to 18 million people
over 65 years of age who are medical problems.
Sixty-five is a figure that has been arbitrarily se-
lected as the beginning of old age, but it is well
recognized that chronologic age is not an accurate
yardstick for measuring the physiologic process of
aging. Everyone knows elderly people who are
vigorous and vital, and who set examples of in-
dustry and of service that younger people might
well emulate. Until incapacitated by the infirmities
incident to aging, grandmother’s hands are never
idle, and grandfather tends his garden, refinishes
the furniture or keeps occupied as a disciple of
Isaac Walton.

The most serious problem of the aged is a social
one that mistakenly has been labelled medical.
Dr. Robert Kemp,* an Edinburgh physician, has
pointed out in an excellent article in lancet that
the common mistake in Britain was the belief that
old people were in hospitals because they were
ill. Though the National Health Service has been
in operation since 1948, Kemp states that “in the
hospital we find more and more people who have
been admitted for social reasons.” He points out
that failure of morale, rather than illness, causes
most of the bleakness of old age. The social re-
sponsibility for the aged is not a medical responsi-
bility, but instead is an obligation of the family
and of the community.

Another facet of the problem which should be
given some emphasis is that making hospitaliza-
tion too easy may well prove to be a disservice to
the elderly. The conscientious physician does
everything possible to keep his patient well and
out of the hospital. The common infirmities inci-
dent to aging are best treated in the home, in the
office or in the outpatient department. Admission
of the aged man or woman to a chronic hospital
may appear to be a simple solution for a difficult

* Kemp, R.: Old age is not disease, lancet, 1:94-95, (Jan.
13) 1962.

problem, but attrition from infection in such insti-
tutions is a serious deterrent. The elderly patient
with a pulmonary or cardiovascular impairment is
a likely candidate for infection by the hospital
staphylococcus.

If the King-Anderson Bill or a similar proposal
were to pass, overcrowding and overutilization of
the hospital would be inevitable, and would add to
a medical problem that already is a very serious
one.

Pneumonia Still Poses Difficult
Problems

Despite all of the advances in the science of
medicine, the accurate diagnosis and the manage-
ment of pneumonia are still difficult. The clinician
is frequently baffled by the contradictions of the
clinical picture and the physical findings, by the
failure of roentgenograms to confirm his clinical
judgment, and by the inability of the laboratory
to resolve the diagnosis. Even with a wide variety
of antibiotics available for the treatment of the
disease, our results are often disappointing or
inconclusive. Few physicians with experience in
caring for adults or children ill with pneumonia
have not been chagrined over a lack of diagnostic
acumen and perplexity over the management of
the disease.

A recent discussion of the diagnosis and man-
agement of infectious pneumonia at the Mayo
Clinic by Morrow, Olsen and Martin* should afford
the individual physician a measure of comfort by
showing him that others share his difficulties, and
in addition, should provide him a better insight
into the problem. Even at the Mayo Clinic, these
authors say, “Infectious pneumonia is a continu-
ing problem in diagnosis and management.”

The Mayo group employ the time-honored
classifications of primary and secondary infection,
and pneumonia is still lobar or lobular. Pneu-
monia may be the initial manifestation of certain
generalized infections, and thus there is a neces-
sity for special diagnostic studies. In their ex-
perience, as it is with the individual practitioner,
the most difficult problem is that of differentiating
pneumonia due to bacteria from pneumonia due
to viruses. The pneumococcus is still the most
common cause of bacterial pneumonia, the disease
is usually lobar in type, and ordinarily penicillin
therapy is quickly effective. Staphylococcal pneu-
monia is usually lobular in type, and frequently
occurs as a superinfection in patients hospitalized
for other diseases, particularly viral pneumonia.
Hemophilus influenzae is usually a secondary in-

* Morrow, G. W., Jr., Olsen, A. M., and Martin, W. J.: In-
fectious pneumonia: continuing problem in diagnosis and
management, proc. staff meet, mayo clinic, 37 :151-162,
(Mar. 14) 1962.

423

424

Journal of Iowa Medical Society

July, 1962

vader. The Friedlander bacillus occasionally caus-
es pneumonia in debilitated patients. Sputum and
blood cultures taken before the start of antibiotic
therapy should provide a bacterial diagnosis with-
in 24 to 48 hours.

The Mayo group have abandoned the term “pri-
mary atypical pneumonia,” which designated a
patchy infiltrate of the lung that did not respond
to antibiotic therapy. There still is disagreement
concerning the etiology, but it has been attributed
to infections by several different viruses. Many
primary pneumonias do not respond to antibiotic
therapy, and their clinical course suggests a viral
infection. So common is this type of infection that
it is now considered typical rather than “atypical.”
Proved viral pneumonia has usually been found
to be the result of adenoviruses or to influenza
viruses, types A and B. This has been demon-
strated by paired serologic determinations which
have shown an increase in antibody titer. The
authors quote Evans, who reported that in only
28.1 per cent of cases can the etiologic diagnosis
of pneumonia be established accurately. Of that
28.1 per cent, 8.2 per cent are of bacterial origin,
and 19.9 per cent are caused by viruses. In the
remaining 71.9 per cent of cases of pneumonia, the
cause is unknown, but they are presumed to be
of viral origin. The early diagnosis of viral infec-
tions is still largely experimental.

From their experience, the authors have found
that certain roentgenographic characteristics help
differentiate bacterial from viral pneumonia, but
in the majority of cases the roentgenogram has
merely confirmed the presence of pneumonia.
Formerly, a leukopenia and relative leukocytosis
was considered characteristic in atypical pneu-
monia. Today, in viral pneumonia, the leukocyte
count is normal or may be elevated to 15,000/cu.
mm., and often the neutrophils comprise 90 per
cent of the leukocytes. In bacterial pneumonia the
leukocyte count is usually elevated to 15,000/cu.
mm. or more, and the percentage of neutrophils
is usually increased. The erythrocyte sedimenta-
tion rate is elevated in both viral and bacterial
pneumonia, though a significant rise to 100 mm.
or more in one hour is more characteristic of a
viral infection. Sputum culture ordinarily is posi-
tive in bacterial pneumonia and negative in viral
infections, though in viral diseases the sputum
may be contaminated by secretions from the naso-
pharynx, and the result of the culture can be mis-
leading. A positive blood culture is found only in
bacterial disease. Positive cold agglutinins and
positive streptococcus MG titers are thought to be
nonspecific responses to a viral infection.

Ordinarily there are certain clinical character-
istics which aid the physician in differentiating a
bacterial from a viral infection. Typically, bac-
terial pneumonia begins with chills and fever. A
productive cough develops early, localized pleuritic
pain is frequently present on the first or second
day, and the pulse is rapid and correlates with the

degree of fever. The patient with viral pneumonia
complains of headache, aching of the muscles,
malaise and fever. A cough develops only after
several days, and pleuritic pain is relatively un-
common. In contrast to the patient with lobar
pneumonia, an individual with viral disease has
a pulse that is slow in relation to the degree of
his fever.

According to the Clinic physicians, conjuncti-
vitis and palatal petechiae are frequent in viral
infections, but are rare in bacterial pneumonia.
Pulmonary findings in viral disease often do not
fit the roentgenographic changes. Early in the dis-
ease, rales may be heard, but the roentgenographic
changes are questionable or minimal. Later, the
roentgenographic evidence of pneumonia may ex-
ceed the physical findings, or with a paucity of
physical findings the roentgenogram may reveal
an extensive pneumonia. In bacterial pneumonia,
there is usually a close correlation between the
physical findings and the roentgenographic chang-
es. Consolidation occurs in both forms of the dis-
ease, but it is usually more prominent and more
extensive in bacterial pneumonia. Pleural effusion
is common in bacterial disease, but is unusual and
minimal in viral disease.

The philosophy of management, as expressed by
the Mayo clinicians, is based on the premise that
the majority of primary pneumonias do not re-
spond to antibiotic therapy, and the clinical pic-
ture in these infections suggests a viral etiology.
With this premise, a serious effort is made to dif-
ferentiate between viral and bacterial disease.
Unless the patient is critically ill, one should
await the results of sputum culture and sensitiv-
ity determinations before starting antimicrobial
therapy. An exception to this procedure is the
critically-ill patient in whom a staphylococcal in-
fection is suspected. In such an individual, ap-
propriate treatment is started immediately after
sputum and blood cultures have been taken. In
patients not critically ill, antibiotics are given only
to those who give clinical and bacteriologic evi-
dence of an infection due to a susceptible organ-
ism.

The Mayo group prefer to treat the viral pneu-
monia patient in the home, if at all feasible. Hos-
pitalization may result in a superinfection by
virulent bacteria. The tetracycline drugs are used
only in infections in which other drugs are less
effective. This practice is based on the hazard of
secondary staphylococcal invasion, which results
from the suppression of the gram-negative flora
of the body. In pneumococcal pneumonia, penicil-
lin remains the drug of choice. In patients al-
lergic to penicillin, erythromycin is administered.

The authors conclude that, in the diagnosis and
treatment of pneumonia, there is no substitute for
clinical acumen combined with a thorough knowl-
edge of antimicrobial substances and their appli-
cation.

Vol. LII, No. 7

Journal of Iowa Medical Society

425

Praise for Dr. Blanding

A recent press report quoted Sarah Gibson
Blanding, Ph.D., president of Vassal' College, in
an emphatic admonition to her student body.
She declared that college women are expected to
conduct themselves as mature individuals and to
uphold the highest moral standards. She cour-
ageously pointed out the hazards of social drink-
ing and of sexual promiscuity. It is encouraging
that the president of a leading college for women
has realistically approached this serious problem
among the youth of today.

A rising illegitimacy rate and an increase in
venereal disease among teen-agers are evidence of
increased promiscuity. Excessive drinking impairs
restraint, and drinking among college students is
far too common. Libidinous literature, off-color
stage plays and salacious movies are the prize-
winning arts of today, contributing to form an of-
fensive and unwholesome climate for youth. Pres-
ent-day society gives too much emphasis to sex
and to physical glamor, and too little emphasis to
character and wholesomeness. Disregard of moral
codes by important people, and by so-called im-
portant people, gives the impression that flaunting
of convention and disregard of traditional re-
straints constitute smart, sophisticated behavior.

The college woman has been freed from par-
ental supervision and from the inhibitions im-
posed by her home community. She has entered
a more sophisticated world of many pressures.
She is exposed to a multitude of “isms” that sug-
gest or have become associated with a departure
from previously accepted ethical codes.

The libido is probably at its peak just at the
time when our young people are of high school
and college age. In primitive cultures in which
education had an insignificant role, marriage was
consummated at sexual maturity, but in our com-
plex society education and a degree of emotional
maturity are considered necessary before mar-
riage. Judeo-Christian ethics have imposed re-
straints upon all of the age levels, and in our
culture the family is predicated upon that philos-
ophy. Departure from long-established ethical
codes and disregard of restraints constitute im-
moral behavior, and despite the changing mores
of our times, there is no uncertainty about the
immorality of premarital physical intimacy and
premarital sexual relations.

Far more necessary than admonition, of course,
is real character-building in the home, supple-
mented by moral and religious training in the
home, the school and the church. It is high time
for educational leaders to make a forthright
demand for high moral standards among students.
Parents and society in general are indebted to
Dr. Blanding for taking a positive rather than a
laissez faire attitude toward a distressing problem
that exists in many educational institutions.

New Trends in Physician-Clergyman
Cooperation*

A Department of Medicine and Religion, with
the goal of developing a closer relationship be-
tween physician and clergyman in the care of the
patient, has been set up by the American Medical
Association during the past year. It is a part of
the Field Service Division of the AM A, and the
Rev. Dr. Paul B. McCleave is its director.

This development is indicative of a healthy
change in the attitudes of both professions, for in
the past both of them have been jealous of their
own fields. Discoveries in psychosomatic medicine
have brought a new respect for the wholeness of
the individual — including the body, the mind and
the soul or psyche. These findings reinforce the
statement made by Dr. Weir Mitchell: “ ‘Tis not
the body, but the man is ill.” In this age of ultra-
specialization in all fields of endeavor, it is pos-
sible that the totality, the wholeness, of the per-
son may have been forgotten in the effort to treat
the particular problem. The mental outlook, the
life philosophy, the desire to get well or not to
get well, and therefore the religious faith or lack
of faith of the individual has a bearing upon his
recovery from any particular illness, type of sur-
gery or accidental injury. Man is a whole person,
a completely interrelated entity, and therefore it
becomes necessary to treat him in his totality.

How often the physician and the clergyman
(priest, rabbi or pastor) meet at the bedside of
the patient (parishioner) with mutual concern for
his welfare. Each can learn from the other. Each
profession has plenty of work to do, and need
have no fear that the other is threatening his po-
sition. Today there is the great possibility that
the patient may recover more rapidly if these at-
tendants learn to communicate and cooperate with
one another, each realizing that he is not sufficient
unto himself.

More and more clergyman of all faiths are being
educated in the areas of depth psychology, coun-
seling, and the interrelationship of medicine and
religion. Recently, as physicians and clergyman
have compared notes, they have been amazed at
the great similarity between the art of medicine
and the art of pastoral care. Both professions are
interested in the health and wholeness of the in-
dividual— including the physical, the mental, the
emotional and the spiritual aspects of man. Dis-
orders in any of these areas cannot be treated
separately if the person is to be helped properly.

When an individual becomes ill or needs sur-
gery, and is hospitalized, he begins to ask many
questions, if only there is someone present who
will lend a listening ear. Maybe for the first time
he rethinks the meaning of life, of the values in
his job or profession, and often of his relationship

* The Reverend Mr. Russell C. Striffler, chaplain at Iowa
Methodist Hospital, Des Moines, wrote this editorial at the
invitation of the editors of the journal.

426

Journal of Iowa Medical Society

July, 1962

to God. In the hospital the person who has been
very mature, very self-sufficient, very capable of
making decisions in the business and social world,
is rendered quite helpless. He becomes dependent,
and often regresses to an earlier stage of emotional
development, or at least reacts on a relatively im-
mature level. If someone will take the time to
listen to him, he will ask, “Why did this happen
to me?” “Is there any relationship between wrong-
doing (sin) and suffering?” “What will happen
if I cannot get well?” “What about my family and
my job?” No pious platitudes will satisfy the
searching mind of the patient, but perhaps the
physician and the clergyman, both being conscious
of these thoughts and feelings, may be able to
help the patient clarify his thinking and come to
some of his own conclusions.

Doorways of cooperation are slowly opening, as
individual members of both professions learn to
know each other better. In this process, defenses
are broken down, means of communication are im-
proved, and physicians and clergymen learn that
each of them needs the other, since both of these
SERVICE professions are interested in one and
the same person — THE PATIENT.

Glomerulonephritis and Impetigo

We have become accustomed to look upon im-
petigo as an innocuous superficial infection of the
skin having no great clinical significance, and in
our offices it has been a time-consuming nuisance.
It is thus a complete surprise to learn, in a report
from Emory University, of a rather large group of
patients with acute glomerulonephritis in associa-
tion with impetigo.*

For a long period of time, a causal relationship
has been recognized between an antecedent beta
streptococcal infection and glomerulonephritis. The
renal lesion has usually occurred after an acute
respiratory infection, and only rarely following
a skin infection.

In the Atlanta study, 94 children with acute
glomerulonephritis were seen in a three-year
period from 1958 through 1960. The absence of a
history of an antecedent acute streptococcal re-
spiratory infection in a large percentage of the
patients and the presence of an associated impetigo
in many of the children stimulated a more careful
study of the disease and its possible relationship
to impetigo. After careful analysis it was deter-
mined that nine of the patients had had no prior
infection, five of the children had had miscellane-
ous types of infection, 16 had had sore throat, and
64 (68 per cent) had had impetigo.

Throat cultures on 63 of the patients revealed a

*Blumberg, R. W., and Feldman, D. B.: Observations on
acute glomerulonephritis associated with impetigo, j. pediat.,
60:677-685, (May) 1962.

mixed bacterial flora with no predominating or-
ganisms. Beta hemolytic streptococci were recov-
ered from three. In most of the patients, the im-
petigenous lesions were dry and crusted, and did
not lend themselves to culture. Sixteen of the
lesions were cultured, and beta hemolytic strep-
tococci were recovered from eight patients in
whom simultaneous throat cultures were negative.
In three patients, positive cultures of the lesion
were obtained but throat cultures were not taken.
Antistreptolysin 0 titers were determined in 38
of the patients in the series, and they were found
elevated in 36, and within the normal range in
two patients. In 13 cases the titer exceeded 500
Todd units.

Of the 94 patients, 77 were Negro and 17 were
white. The usual ratio of Negro to white at the
Grady Hospital is 2:1. The cases were equally
distributed between boys and girls. The series was
unusual in that almost half of the patients were
under five years of age. The seasonal distribution
was significant in that cases associated with im-
petigo had their highest incidences in August and
September. In contrast, the cases associated with
an antecedent respiratory infection occurred most
frequently from November through January.

The typical urinary findings characteristic of
acute glomerulonephritis were demonstrated in
all but two patients in the series. Thirty-three of
89 patients tested had either an elevated blood
urea nitrogen or non-protein nitrogen level on
admission. Facial edema was the most common
presenting symptom. Fever was not a common
symptom of those patients in whom impetigo was
associated with the disease. Eighty per cent of
the patients had hypertension. On radiologic ex-
amination, 76 per cent were found to have cardiac
enlargement, and pleural fluid was visible in 56
per cent. Pulmonary congestion was demonstrable
in 82 per cent of the cases.

The management of this group of patients con-
sisted of bed rest, a low-sodium diet and the ad-
ministration of penicillin for 10 days. All but 18
received antihypertensive therapy with reserpine,
and 55 patients were also given magnesium sul-
phate as part of the initial treatment. Seventy of
the 94 patients were digitalized, and digitalis was
continued until the blood pressure had returned to
normal and all signs of cardiac failure had dis-
appeared. One child received peritoneal dialysis
because of increasing acidosis and a non-protein
nitrogen level of 232 mg. per cent. All patients
recovered, and in follow-up studies from six to
24 months later, there was no evidence of chronic
nephritis in any of the 94 patients.

The authors attributed the high incidence of
acute glomerulonephritis associated with impetigo
in this group of patients to several causes. The
patients admitted to the hospital in which this
study was made are from a low socioeconomic
gi’oup, and impetigo in that class of patients is

Vol. LII, No. 7

Journal of Iowa Medical Society

427

exceptionally frequent. Most of the skin infections
had not received treatment prior to admission to
the hospital. Patients with acute streptococcal in-
fections of the upper respiratory tract usually are
ill and have sufficient fever to prompt medical con-
sultation early. The early and effective treatment
of most impetigo cases explains the relatively low
incidence of nephritis from this cause.

Fifth Column

The following column appeared in the May 22
issue of the London times. Though the distortions
that it contains actually originated with an Ameri-
can, one might have supposed that they came
straight from Moscow.

Pill-Swallower Civilization of America

Attack by Health Official

Too Many Anxieties
From our own correspondent

Washington, May 21. The United States is described
by a public health official as the wealthiest country in
the world, and one of the unhealthiest. He blames the
public, the medical profession, and the medical schools
for the poor state of American health.

Dr. Herbert Ratner, a professor at Loyola Univer-
sity medical school, Chicago, and a commissioner of
health in Illinois, makes these observations in an
interview published by the Centre for the Study of
Democratic Institutions in its series on the American
character.

Dr. Ratner says the United States is the most over-
medicated, most over-operated, most over-inoculated
country in the world, and the most anxiety-ridden in
regard to health. “We are flabby, overweight, and
have a lot of dental caries, fluoridation notwithstand-
ing. Our gastro-intestinal system operates like a sput-
tering gas engine.

Hearts and Heads

“We can’t sleep; we can’t get going when we are
awake. We have neuroses; we have high blood pres-
sure. Neither our hearts nor our heads last as long as
they should. Coronary disease at the peak of life has
hit epidemic proportions. Suicide is one of the leading
causes of death — fourth between the ages of 15 and
44. We suffer from a plethora of the diseases of civili-
zation.”

The United States has become a nation of pre-
sumably healthy persons who cannot function well
because they are full of anxieties, he said. “The most
radical condemnation of our society and culture and
American character is that one out of 10 babies — and
there are about four million born in this country every
year — will enter a mental hospital at some time in
his life. A recent house to house count in one com-
munity indicated that one out of eight Americans suf-
fers from a psychiatric disturbance severe enough to
warrant treatment.”

Dr. Ratner believes that Americans look upon health
in materialistic terms. “They think of health as some-
thing that can be bought, rather than a state to be
sought through an accommodation to the norms of
nature. We have become increasingly a paying animal,
as if health were solely a commodity of the market
place.”

Drugs as Panacea

Although the United States is the best place in the
world in which to have a serious illness, it is one of
the worst for non-serious illness. “We impose our
life-saving drugs and techniques, intended for serious
ailments, on minor, even trivial illnesses. . . .”

Barbiturates, stimulants and tranquilizers are the
most misused drugs in the country. “We consume fan-
tastic amounts of these drugs. For many they are used
as a panacea to solve personal problems; they are
practically replacing the functions of the virtues in
striving for a sane and well ordered life. . . . We are
becoming a pill-swallowing civilization, and God help
us as a nation and as individuals when the new con-
traceptive pill really gets going.”

Dr. Ratner also complains of wide-spread bottle
feeding. “We have now recently brought into the hos-
pital nursery — that efficiently conducted displaced-
persons concentration camp — a mechanical heart beat
to substitute for the reassuring heart beat that baby
would normally hear when at its mother’s bosom. It
is called Securitone — shades of Wells, Huxley and
Orwell!”

A Horse Outlook

Most medical schools are confused about their basic
purpose, and they no longer know if their goal is to
turn out physicians or research men. Doctors, he says,
need a genuine philosophy of medicine permitting in-
dependent evaluation of current research, and this
American doctors do not get. “They become, instead,
sitting ducks for the canned speeches of the drug-house
retail [sic] men. . . . The modern medical school is
really not much different from the veterinary school.
It could for the most part just as well have the horse
for its subject.”

Dr. Ratner has few fears about a national health
service. “The medical profession has the obligation to
see to it that every patient has the medical care he
needs, and if this means what they call ‘socialized medi-
cine’ the medical profession has to be ready to accept
it.”

The foregoing, we submit, is an example of
“the big lie.” Somehow, such assertions are par-
ticularly incongruous, dangerous and in poor taste
when they come from a man trained in the sci-
ences. We are reminded of the following lines from
the BOOK OF ECCLESIASTES:

“Dead flies cause the ointment of the apothecary
to send forth a stinking savour: so doth a little
folly him that is in reputation for wisdom and
honour. . . .

“Surely the serpent will bite without enchant-
ment; and a babbler is not better.

“The words of a wise man’s mouth are gracious;
but the lips of a fool will swallow up himself.”

428

Journal of Iowa Medical Society

July, 1962

Presidents Page

In accordance with an action taken by the IMS House of Delegates
on May 16, 1962, your officers have agreed with the Iowa Society of
Osteopathic Physicians and Surgeons on a plan that will permit profes-
sional relationships between all doctors of medicine and those osteo-
pathic physicians and surgeons who meet certain qualifications.

Eligible osteopathic physicians and surgeons may apply through
ISOPS to the MD/DO Liaison Committee, and each application will
be referred to the medical society of the county where the applicant
resides, for its approval. Final action on each approved application
will be taken by the IMS Judicial Council.

Criteria for the county medical society’s evaluation were proposed in
the Supplemental Report of the Osteopathic and MD/DO Liaison Com-
mittees, presented during the 1962 annual meeting, and the House of
Delegates approved them when it accepted the report of the Judicial
Council acting as a reference committee. They can be found on page
474 of this issue of the journal.

IMS members will recall that in June, 1961, the AMA House of
Delegates adopted a report that said, in part: “Recognition should be
given to the transition presently occurring in osteopathy, which is evi-
dence of an attempt by a significant number of those practicing osteo-
pathic medicine to give their patients scientific medical care. This
transition should be encouraged so that the evolutionary process can
be expedited. [This] policy should now be applied individually at the
state level according to the facts as they exist. . . .” Actions similar to
Iowa’s have been taken in a number of states, including Colorado,
Ohio, Missouri, Kansas, New Jersey and Delaware.

President

BOOKS RECEIVED

PRACTICAL ANESTHESIOLOGY, by Joseph F. Artusio, Jr.,
M.D., and Valentino D. B. Mazzia, M.D. (St. Louis, The
C. V. Mosby Company, 1962. $7.75).

PEDIATRICS, THIRTEENTH EDITION, by L. Emmett Holt,
Jr., M.D., Rustin McIntosh, M.D., and Henry L. Barnett,
M.D. (New York, Appleton-Century-Crofts, Inc., 1962.
$18.00).

ESSENTIALS OF PEDIATRIC PSYCHIATRY, by Ruben
Meyer, M.D., Morton Levitt, Ph D., Mordecai L. Falick,
M.D., and Ben O. Rubenstein, Ph.D. (New York, Appleton-
Century-Crofts, Inc., 1962. $6.00).

TUMOR VIRUSES OF MURINE ORIGIN (Ciba Foundation
Symposium), ed. by G. E. W. Wolstenholme, M.B., and
Maeve O’Connor. (Boston, Little, Brown and Company,
1962. $10.75).

CONGENITAL CARDIAC DISEASE: A REVIEW OF 357

CASES STUDIED PATHOLOGICALLY, by Robert S. Fon-
tana, M.D., and Jesse E. Edwards, M.D. (Philadelphia, W. B.
Saunders Company, 1962. $10.00).

TEXTBOOK OF OPHTHALMOLOGY, SEVENTH EDITION,
by Francis Heed Adler, M.D. (Philadelphia, W. B. Saunders
Company, 1962. $9.00).

PSYCHOLOGICAL DEVELOPMENT IN HEALTH AND DIS-
EASE, by George L. Engel, M.D. (Philadelphia, W. B.
Saunders Company, 1962. $7.50).

INTERPRETATION OF SIGNS AND SYMPTOMS IN DIF-
FERENT AGE PERIODS: PEDIATRIC DIAGNOSIS, SEC-
OND EDITION, by Morris Green, M.D., and Julius B. Rich-
mond, M.D. (Philadelphia, W. B. Saunders Company, 1962.
$13.00).

MEDICAL STATE BOARD QUESTIONS AND ANSWERS, ed.
by Harrison F. Flippin, M.D. (Philadelphia, W. B. Saunders
Company, 1962. $9.50).

TREATMENT OF INJURIES TO ATHLETES, by Don H.
O'Donoghue, M.D. (Philadelphia, W. B, Saunders Company,
1962. $18.50).

HANDBOOK OF PHYSIOLOGY. SECTION 2: VOLUME I,
ed. by W. F. Hamilton and Philip Dow. (Baltimore, The
Williams & Wilkins Company, 1962. $24.00).

FINANCING MEDICAL CARE, ed. by Helmut Schoeck.
(Caldwell, Idaho, The Caxton Printers, Ltd., 1962. $5.50).

BOOK REVIEWS

Clinical Pathology: Application and Interpretation,

Third Edition, by Benjamin B. Wells, M.D., Ph.D.

(Philadelphia, W. B. Saunders Company, 1962. $9.00).

This text maintains the unique format characteristic
of the previous editions. It is written from the clini-
cian’s point of view. A subject is approached by con-
sidering the clinical problem first. Then, a discussion of
the useful laboratory tests follows. The procedures, of
course, may be of varying types, yet all are germane
to the specific clinical problem. Test methodology and
theory are minimized. Sound consideration is given to
the relative usefulness of each procedure. The text is,
therefore, altogether practical and should find wide
usage.

The author says, “This book is again offered to medi-

cal students and physicians as a guide in the applica-
tion and interpretation of clinical laboratory studies.”
Many physicians fail to take advantage of the con-
sultive service of the clinical pathologist to whom they
submit specimens for examination. If they would do
so, most of them would have little or no need for this
text. However, in some localities a clinical pathologist
is not immediately available for the discussion of cases
and for suggestions as to test procedures. Medical
students at all levels of training should find the book
quite useful.

It is noteworthy that the third edition of clinical
pathology includes numerous new features that bring
it up to date quite adequately, yet reasonable brevity
and simplicity have been maintained. — David Baridon,
Jr., M.D.

Internal Medicine in World War II: Volume I — Activi-
ties of Medical Consultants, ed. by Col. John B.
Coates, Jr., MC, and W. Paul Havens, Jr., M.D.
(Washington, D. C., Office of the Surgeon General,
Department of the Army, 1961. $7.50) .

This 827-page volume deals with the roles of various
medical consultants in all theatres during World War
II. It is very well documented and well illustrated, and
makes for interesting reading, not only for men who
were in the service but for anyone else who is inter-
ested in the problems encountered by the Army Medi-
cal Corps in all parts of the world.

The lessons learned, both good and bad, as brought
out in this volume will undoubtedly serve as a guide
for the more effective utilization of medical consultants
in any future disasters. — Pat M. Cmeyla, M.D.

Renal Biopsy: Clinical and Pathological Significance

(A Ciba Foundation Symposium), ed. by G. E. W.

Wolstenholme, M.B., and Margaret P. Cameron, M.A.

(Boston, Little, Brown and Company, 1962. $10.50) .

Under the sponsorship of the Ciba Foundation for
the Promotion of International Cooperation in Medical
and Chemical Research, a symposium on “The Clinico-
Pathological Significance of Renal Biopsy” was con-
ducted in London during March, 1961, under the chair-
manship of Dr. Arnold R. Rich, of Johns Hopkins Uni-
versity. The papers presented, the remarks of the
chairman and the discussions by 29 pathologist and
clinician participants have been presented in excellent,
beautifully-illustrated form in this 395 page book.

As Dr. Rich brought out in his closing remarks,
“Only biopsy can supply fresh renal tissue at particular
desired times during human renal diseases and, as is
well known, fresh tissue is required for trustworthy re-
sults in electron microscopy and in the study of cellu-

429

430

Journal of Iowa Medical Society

July, 1962

lar chemistry, particularly enzyme chemistry. No other
organ in the body has so complex a functional unit as
the kidney. The advances in knowledge of the finer
structure of the nephron, which are being gradually
contributed by electron microscopy, have already raised
fascinating and basically important problems concern-
ing the correlation between the new structural discov-
eries and normal and disturbed renal function.”

With so much attention given to the study of finer
structural details of the kidney in health and disease,
the volume should be of timely value to those inter-
ested in renal research and also to those practicing in
institutions where percutaneous renal biopsy is under-
taken.— R. F. Birge, M.D.

Atlas of Clinical Endocrinology, Second Edition, by

H. Lisser, M.D., and Roberto F. Escamilla, M.D. (St.

Louis, The C. V. Mosby Company, 1962. $23.00) .

This is the second edition of an atlas which was
originally published in 1957. As the authors point out,
there are many excellent textbooks on endocrinop-
athies, in which the overwhelming emphasis is on
the written word. This atlas was produced to stress
the pictorial aspects, and magnificent results have
been achieved in depicting various stages and manifes-
tations of endocrine disease.

The text is in outline form, and each entity is con-
sidered under definition; symptoms, important and
less significant; physical signs, important and less sig-
nificant; laboratory tests, confirmatory procedures, and
less essential; differential diagnosis; treatment; and
prognosis. Since it is in outline form, the text is
necessarily somewhat dogmatic, and only brief men-
tion is made of theories other than those of the au-
thors. Many excellent photographs, with complete ex-
planatory legends, are presented with each entity. The
authors stress the history and the physical examina-
tion— especially observation — throughout the book.

A complete appendix is included, giving the normal
values for laboratory tests helpful in endocrine diag-
nosis, information on endocrine preparations useful in
everyday practice, including dosages and indications
for each of the endocrine glands, and tables setting
forth growth standards and development manifesta-
tions for each of the various ages of life.

This truly is an atlas of endocrinology designed
especially for clinicians. It is a valuable book, and it
would be a worthwhile addition to any physician’s
library. — George G. Spellman, M.D.

The Dynasty, by Charles H. Knickerbocker, M.D.

(New York, Doubleday & Co., 1961. $4.50) .

John Crest, a poor boy with determination and am-
bition, and a steady student, enters medical school. In
due course he graduates, then internes. He marries
Emerald Parkindale. The Parkindales are a medical
family — a dynasty.

Emerald is moody, though casual in matters of sex.
Her father, a general practitioner in a small town, is
unethical and domineering. A brother is surgically tal-
ented, but superficial and cynical. The grandfather,
dean of the medical school, is brilliant but frustrated.
An uncle, a big-city plastic surgeon, is gifted but given

to sleeping with certain of his re-done female patients.

Young Dr. Crest, an idealist, enters practice with his
father-in-law. In addition to the conscienceless Dr.
Parkindale, there are five other doctors in town: one
a narcotic addict and alcoholic (formerly a promising
brain surgeon), one a dandified old man, and three
others who are almost faceless nonentities.

These unusual and somewhat jaded characters go
about their day-by-day activities, and therein lies the
story. Needless to say, except for our hero, the general
behavior is shocking and scandalous, although some-
how almost everyone seems more calloused than evil.
If fictional doctors must be bad, as so many novelists
apparently insist, one could almost prefer a Dr. Jekyll
and a Dr. Caligari.

Yet for all the distortion in the characters, the narra-
tive is interesting, and the medical situations are
authentic. Best of all, the author seriously and candidly
attempts to come to grips with the perplexities of the
practice of medicine — the declining prestige of the doc-
tor, the conflicts between the art and the science of
medicine, the rationale for the “conspiracy of silence”
among doctors, the uneasy accommodation between
service and fee for service, and the deep sense of fail-
ure occasioned by the death of a patient.

The author is a doctor in private practice. He has
been able to write a book, get it published, tell a story,
and discourse with sincerity on philosophical problems
of the medical profession. All in all, that’s quite an
accomplishment. — Daniel F. Crowley, Jr., M.D.

National Bilirubin Survey

In order to stimulate interest in the accuracy
of bilirubin determinations, the College of Ameri-
can Pathologists Standards Committee announces
a National Bilirubin Survey, available to all phy-
sicians and hospitals.

Accurate bilirubin measurements are of great
importance in decisions as to the need for ex-
change transfusions in cases of newborn erythro-
blastosis fetalis. They are of great importance in the
differential diagnosis of the various icteric syn-
dromes in patients of all ages. They are important
in evaluating prospective blood donors. In all of
these cases, a poorly calibrated technic will lead
to serious mistakes in the care of the patient.

Bilirubin measurements must be consistent
from year to year so that treatment is based
upon the same criteria in successive patients.
Therefore, reliable bilirubin standards should be
utilized with stable photoelectric photometers.

Participants in the Survey will receive a set of
survey samples. Following the Survey, a critique
of bilirubin standards and methods of analysis
will be provided them. Questions rising during the
Survey may be directed to the Committee.

Those who wish to participate are invited to
send the $8 enrollment fee to the Standards Com-
mittee, College of American Pathologists, Pru-
dential Plaza, Chicago 1, Illinois. Applications must
be received no later than August 1, 1962.

Hearing CcnJertaticn

The Incidence of Hearing Loss

The Committee on the Conservation of Hearing
for the State of Iowa, which is presenting a series
of articles in the journal, consults with and ad-
vises all agencies interested in the problems of
hearing impairment. Its services are available to
industry, agriculture, education and to the broad
spectrum of public health and welfare services
within the state.

The Committee has been officially sponsored by
the Iowa State Department of Health since 1957.
However it was first formed in 1949, and has been
continuously active under the leadership of Dr.
Dean M. Lierle, head of the Department of Oto-
laryngology and Maxillofacial Surgery at S.U.I.
From the first, the Committee has been interdis-
ciplinary in composition and purpose.

*C. M. Kos, M.D. (chairman), otologist in private practice,
Iowa City.

Joseph Wolvek (executive secretary), consultant, Hearing
Conservation Services, State Department of Public Instruc-
tion, Des Moines.

L. E. Berg, superintendent, Iowa School for the Deaf,
Council Bluffs.

Dale S. Bingham, consultant, Speech Therapy Services,
State Department of Public Instruction, Des Moines.

Paul Chesnut, M.D., private practitioner and member of
AAGP, Winterset.

James F. Curtis, Ph.D., head. Department of Speech Pa-
thology and Audiology, S.U.I., Iowa City.